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NEUROLOGICAL AND MENTAL DIAGNOSIS 



THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
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THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



NEUROLOGICAL AND MENTAL 
DIAGNOSIS 

A MANUAL OF METHODS 



BY 
L. PIERCE CLARK, M.D. 

SENIOR ATTENDING PHYSICIAN, HOSPITAL FOR NERVOUS DISEASES 
NEW YORK ; VISITING NEUROLOGIST TO THE RANDALL'S ISLAND 
HOSPITALS AND SCHOOLS, NEW YORK J CONSULTING NEU- 
ROLOGIST TO THE MANHATTAN STATE HOSPITAL, N.Y., 
AND THE CRAIG COLONY FOR EPILEPTICS, SONYEA, 
N.Y. ; ASSISTANT NEUROLOGIST, VANDERBILT 
CLINIC (COLUMBIA UNIVERSITY); FELLOW 
OF THE AMERICAN NEUROLOGICAL 
ASSOCIATION, ETC. 

AND 

A. ROSS DIEFENDORF, M.D. 

LECTURER IN PSYCHIATRY IN YALE UNIVERSITY ; ASSISTANT PHYSI- 
CIAN AND PATHOLOGIST, CONNECTICUT HOSPITAL FOR INSANE J 
MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, OF 
THE NEW YORK NEUROLOGICAL ASSOCIATION, OF THE NEW 
YORK PSYCHIATRICAL SOCIETY, AND OF THE AMERICAN 
MEDICO-PSYCHOLOGICAL ASSOCIATION, ETC. 



Nefo gorfc 

THE MACMILLAN COMPANY 

1908 

All rights reserved 



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COPYBIGHT, 1908, 

By THE MACMILLAN COMPANY. 



Set up and electrotyped. Published June, 1908. 



Norfaoob $r«« 

J. S. Cushing Co. — Berwick & Smith Co. 

Norwood, Mass., U.S.A. 



PREFACE 

This volume is designed to aid the student 
and general practitioner to make thorough and 
systematic examinations in nervous and mental 
diseases. A definite method of procedure is laid 
down in both lines of examination in order that 
proper analysis may be easily and readily made 
in routine case study either in hospital or private 
practice. The necessity and desirability of form- 
ing correct habits in case examination are in 
line with the advanced teachings of modern 
medicine. The chapter on neurological methods 
is by Dr. Clark and that on mental examination 
is by Dr. Diefendorf. 

THE AUTHOES. 

February 1, 1908. 



CONTENTS 



PAGE 

Methods of Examination in Neurological Diag- 
nosis 1 

Methods of Examination in Mental Diagnosis . 61 

Glossary 157 

Index 185 



vu 



LIST OF ILLUSTRATIONS 



FIG. FACING PAGE 

1. Diagram to illustrate Production of Diplopia by the 

Erroneous Projection 9 r 

2. Paralysis of the External Rectus . . . . . 9 

3. Testing the Grasp with the Dynamometer ... 26 

4. Method of Obtaining the Pupillary Light Reflex . 37 

5. Method of Determining the Corneal Reflex . . 37 

6. Method of Eliciting Biceps-jerks 38 - 

7. Method of Obtaining the Supinator-jerk ... 38 

8. Method of Testing Knee-jerk when not readily pro- 

duced in the Ordinary Way 39 • 

9. Method of Testing the Knee-jerk .... 39 

10. Method of Eliciting the Knee-jerks Simultaneously . 40 

11. Usual Method of Testing for the Foot or Ankle Clonus 41 

12. Method of Testing Plantar Reflex, showing Extensor 

Response of the Great Toe (Babinski's Sign) . .41 

13. Method of Testing the Electric Response of a Muscle 

(Supinator longus) 42 

14. A Diagram of the Motor Points of the Face . . 44 

15. Motor Points for the Arm, Inner Side ... 44 

16. Motor Points for the Arm, Outer Side ... 44 

17. Motor Points for the Thighs. Front View . . 44 

18. Motor Points of the Outer Side of the Leg . . 44 

19. Motor Points, Back of Thighs and Legs ... 44 

20. Sensory Areas of the Skin according to Head. Front 

View 45 

21. Back View 46 

ix 



X LIST OF ILLUSTRATIONS 

FIG. FACING PAGE 

22. Side View 48 

23. Side View 50 

24. Showing Method of Charting Areas of Anaesthesia, 

etc. Front View 59 

25. Showing Method of Charting Areas of Anaesthesia, 

etc. Back View 59 

Plate I. Cytological Changes in Paresis ... 71 

26. Hebephrenic Form of Dementia Praecox, showing 

Silliness and Untidiness 107 

27. Catatonic Stupor with Negativism .... 112 

28. Catatonic Stupor with Flexibilitas Cerea . . .112 

29. Dementia Paralytica, showing the Characteristic Feel- 

ing of Well-being 121 

30. Melancholia, showing Apprehensiveness . . . 128 

31. Paranoia, showing the Erect Carriage and Important 

Attitude 142 



NEUROLOGICAL AND MENTAL DIAGNOSIS 



METHODS OF EXAMINATION IN 
NEUROLOGICAL DIAGNOSIS 

Part I 
CHAPTER I 

In the clinical study of nervous diseases it is 
essential for accuracy and rapidity in diagnosis 
to employ a systematic method of examining 
patients. 

Inasmuch as the forms of nervous diseases 
vary so much in character, no one method of 
examination can always be adhered to rigidly, 
but this does not destroy the feasibility of using 
a more or less definite system of study of the 
cases. In the following pages a general method 
of procedure is indicated which may be modi- 
fied or curtailed to suit individual diseases. 
When a patient is first seen by the physician 
it is often eminently desirable to make a pre- 
liminary rapid survey of the case. Such ex- 
amination sometimes enables the physician to 
make a provisional diagnosis for immediate 
treatment and gain intelligent guidance for sub- 



2 METHODS OF EXAMINATION 

sequent more elaborate and special examination. 
A preliminary examination should cover the es- 
sential points of an extended scheme; a detailed 
record of the latter is shown in a composite case 
which is reproduced here to illustrate the points 
in the examination. In recording the clinical 
findings of the examination intelligible abbre- 
viations should be used wherever possible, but 
the use of symbols is to be discouraged for 
obvious reasons. 

The diagnosis must rest largely, at least in 
most cases, upon the careful objective or direct 
examination of the patient for the detection of 
the signs and symptoms of disease. The history 
of the patient and of the development of his 
disease as gathered from the patient or his 
friends is of course of great importance, but 
the diagnostic indications that are obtained in 
this way are to be used in subordination to the 
objective signs of disease about to be detailed. 
Where the indications derived from the two 
sources conflict, preference is always to be given 
to conclusions that are obtained from an exami- 
nation of the patient. In short, an effort should 
constantly be made to make the diagnosis of 
organic nervous diseases as purely objective as 
possible, the history being used chiefly in sub- 



IN NEUROLOGICAL DIAGNOSIS 3 

ordination to the physical signs for the confirma- 
tion and correction of the diagnosis based upon 
them. 

Complaints. — A brief statement of what the 
patient complains and the duration of the dis- 
order should begin the history. 

Family History. — The cause of death of the 
immediate relatives should be learned as far as 
possible. Particular inquiry is to be made regard- 
ing alcohol, syphilis, tuberculosis, insanity, epi- 
lepsy, or other nervous diseases in the family. 

Personal History. — Noteworthy facts of intra- 
uterine life, birth (its accidents and incidents), 
diseases of infancy, habits, etc., are to be recorded 
in chronological order. Special inquiry is to be 
made concerning evidences of rickets, as this often 
seriously influences the vulnerability of an indi- 
vidual to nervous stresses in later life, particularly 
epilepsy and allied conditions. A very important 
question is that of infectious diseases. Both the 
acute and the chronic infectious diseases may lay 
the basis for nerve troubles that follow directly 
or after an interval of weeks, months, or years. 
Typhoid, smallpox, diphtheria, scarlet fever, 
measles, and influenza are specially to be noted. 
Tuberculosis and nerve diseases are often related. 
The greatest care must be given to the question 



4 METHODS OF EXAMINATION 

of past venereal diseases, particularly syphilis. 
The misuse of alcohol, morphine, cocaine, chloral, 
and other poisons is to be noted. Inquiry should 
also be made concerning long-continued occupa- 
tion with lead, arsenic, mercury, copper, brass, 
etc. Anomalies of sexual life, such as masturba- 
tion and perverse instincts, are to be asked after. 
Injuries, overexertion, and mental excitement play 
very important roles in the etiology. The age 
of puberty, and in women, periods, — frequency, 
pain, etc. Number of children and miscarriages, 
etc., should be carefully inquired into. 

Present Illness. — A chronologically arranged 
account of both the physical and mental symp- 
toms should be followed by a summary of the 
present condition. The inquiry should be specific 
concerning alienation, exaltation, perversion, de- 
pression, defect, stupor, delirium, coma, memory, 
vertigo, convulsions, headache, epileptic or apo- 
plectic attacks, vomiting, etc. 

Physical Examination. — For the present pur- 
pose the special examination can be made under 
the following headings: — 

A. Cranial Nerves 

I. Olfactory. — Injury to this nerve shows itself 
by loss of smell. When the sense of smell has 



IN NEUROLOGICAL DIAGNOSIS 5 

been lost, the person often complains simply of 
loss of taste, as this is the more serious depriva- 
tion. Since disease of the mucous membrane of 
the upper part of the nose may show itself in the 
same way, this must be excluded in case loss of 
smell is found. To test the sense of smell a bot- 
tle stopper or a piece of cotton touched to some 
odorous substance (asafoetida, musk, peppermint, 
cloves) is held for a short time to one nostril 
while the other is closed; the patient is to name 
the substance, or at least to say that the smell 
is familiar. These substances are chosen because 
they act on the sense of smell only; moreover, 
they are easily identified and named. Many per- 
sons, even though such common substances are 
employed, can only recognize an odor, but cannot 
name it; this is, however, practically sufficient, 
as all that is desired is to know that the nerve 
impulses are transmitted. 

Only a small amount of the substance should 
be used in the test. It is used on the bottle 
stopper or on a piece of cotton. This is applied 
to the nostril for only a brief time, because ex- 
cessive stimulation may deaden or paralyze the 
weakened or imperfect sense organs before the 
entire examination is finished. The test is applied 
to the nostrils alternately. 



6 METHODS OF EXAMINATION 

II. Optic. — The only data required are those 
concerning acuteness of vision, the limits of the 
field of vision, and the state of the optic disk. 
The acuteness of vision is tested by the familiar 
test types of Snellen. The types are placed at a 
distance of 6 meters (20 feet), and the patient is 
required to read the letters on the chart; the 
number under the line of smallest letters he can 
see is placed under the number 20. With normal 
vision he should read to the line having the num- 
ber 20; his vision would then be 20/20. If his 
vision is less than this, he moves toward the chart 
until he can see the largest letter; if this is at 8 
feet, his vision is 8/20. If the top letter cannot 
be read, the distance at which the fingers can 
be correctly counted is recorded, thus V fingers 
at one foot, or at seven inches. If this cannot 
be done, the hand is moved before the eyes and 
perception of hand movement is recorded. Where 
no vision of form is found, the perception of light 
(P. L.) is tested by shading and exposing the eye 
or flashing a light into it in a dark room. 

Each eye is tested separately. For testing near 
vision, Jaeger's test type is often used. 

To find the limits of the visual field the hand 
or candle test may be employed. The patient is 
placed with his back to the light about two feet 



IN NEUROLOGICAL DIAGNOSIS 7 

in front of the examiner. One eye is covered; 
with the other eye the patient must look at the 
examiner's eye constantly. The examiner's hand 
is moved in various directions from outside the 
field of vision inward until the patient sees it. 
Both examiner and patient should see the hand 
simultaneously if the field has the normal extent. 
A lighted candle may be similarly used. When 
defective, the field may have temporal, nasal, 
upper or lower contraction. Scotomata are de- 
tected by passing the hand through all parts of 
the field. The blind spot is an anatomical 
affair. 

The examination of the fundus is made with 
the ophthalmoscope by the direct and the indirect 
method. These examinations should be made 
whenever organic lesion of the central nervous 
system (especially in cerebral cases) is sus- 
pected. 

Ill, IV, VI. Motor Oculi, Patheticus, and 
Abducens. — These are examined together, as 
they control all the movements of the eye. The 
patient is required to follow the finger from right 
to left, left to right, up and down, and approach- 
ing in the median plane to the nose. The head 
must be held steady (candle test with red glass 
in front of one eye). 



8 METHODS OF EXAMINATION 

The first point to be tested is (a) limitation of 
movement. This occurs always in the direction 
in which the paralyzed muscles act; limitation 
of movement of the right eye toward the right 
side indicates paralysis of the right external 
rectus, which is controlled by the sixth nerve, 
and so on. 

The next test concerns (b) correspondence of 
the visual axes. Normally the visual axes remain 
parallel for fixation at infinity in all associated 
movements of the eyes. Any non-correspondence 
shows itself as internal or external strabismus in 
one or both eyes. 

The third test concerns (c) secondary deviation 
of the sound eye. This is the most delicate test 
of a slight paralysis in any single eye muscle. It 
never appears in any form of ordinary squint. 
To carry out the test the sound eye is prevented 
from seeing by screening the object by the hand 
or a piece of cardboard; the patient fixes the 
object with the affected eye. The object is moved 
in the direction of one of the muscles. If any 
paralysis is present, the sound eye will move 
farther than the affected one. The increase over 
the primary deviation of the axes is called the 
" secondary deviation." The result is tested by 
covering the paralyzed eye and requiring the 



B A C * 




Fig. 1. Diagram to illustrate 
Production of Diplopia by 
the Erroneous Projection. In 
Consequence of Weakness of 
the Right External Rectus, 
the Image of A formed at the 
Macula, M, of the Left Eye, 
Falls within the Macula of 
the Right Eye at a. But the 
Effect corresponds to that 
Necessary to bring the Mac- 
ula to m (in the Broken Arc). 
Hence B, whose Image is at 
m, seems to occupy the Posi- 
tion of A, and the Image 
formed at a to the Left of m 
is projected to the Other Side 
of A, and seems to occupy 
the Position C, as if it were 
formed at c to the Left of m. 



Fig. 2. Paralysis of the External 
Rectus; Colored Glass over Right 
Eye : Primary Deviation on Look- 
ing toward an Object (0) on the 
Left : Position of Amble Images ; 
Secondary Deviation of the Right 
Eye when the Screen, S, obstruct- 
ing the Fixation of + by this Eye, 
compels Fixation by the "Weak 
Muscle. When the Screens are 
moved, the Right Eye, in Fixing, 
moves Back to the Position of the 
Dotted Outline of the Cornea. 
(In the Diagram of Diplopia the 
Highest White (False) Image 
should have been represented a 
Little Lower than the True Image) . 



IN NEUROLOGICAL DIAGNOSIS 9 

patient to fix the object with the sound eye, which 
will then move to its original position. 

In ordinary squint, or " strabismus," the de- 
viation is present in all movements; it is the same 
no matter which eye is used for fixation. In 
paralysis of one of the eye muscles — " paralytic 
strabismus" — the normal eye produces the pri- 
mary deviation, the affected eye the secondary 
one. The primary deviation indicates defective 
movement, whereas the secondary shows itself 
as an excess of movement. They are similar in 
direction, but opposite in character. 

The fourth test concerns (d) erroneous pro- 
jection of the retinal pictures. The positions of 
objects seen depend upon the feeling of muscular 
effort required to turn the eye to look directly at 
them. When an eye muscle is weakened, a greater 
effort must be made to force it to act; the distance 
which the eye has to turn thus involves more work. 
Consequently the distance between objects ap- 
pears greater than otherwise. The paralyzed eye 
therefore does not correctly locate objects. The 
error is a mental one of judgment. The test is 
made by closing the patient's sound eye and re- 
quiring him to grasp quickly with thumb and 
finger an object in front. He misses toward the 
side of the paralyzed muscle. The degree of the 



10 METHODS OF EXAMINATION 

errors increases with the amount of the paralysis 
and with the extent of the eye-movement required. 
The amount of the error is to be recorded. 

In carrying out the fifth test — for (e) double 
vision — a lighted candle is moved around in the 
field of vision, preferably over a diagram, divided 
into nine squares by two horizontal and two ver- 
tical lines, placed ten feet away. A red glass is 
placed over one eye so that the patient can tell 
which of the two images he sees belongs to that 
eye. The points recorded for each of the nine 
spaces are (1) single or double vision, (2) whether 
the image on the right side belongs to the right 
eye (uncrossed images) or to the left eye (crossed 
images), (3) the relative distance between the 
images, (4) any difference in the level of the 
images, (5) whether they are erect or tipped. All 
these symptoms are in the direction of the normal 
action of the paralyzed muscle. In a paralysis 
of several muscles, solution of the results of the 
test requires great patience. Before drawing 
diagnostic conclusions from the presence of 
diplopia we must show that it is not monocular 
(due to dislocation of the lens), and that it 
ceases in using only one eye. Crossed diplopia 
means that the prolonged ocular axes are not 
crossed. 



IN NEUROLOGICAL DIAGNOSIS 11 

As a sixth fact (/) the characteristic position of 
the head is to be noted. The patient turns the 
head toward the side of the paralyzed muscle and 
in the direction in which the muscle would move 
the eye if not paralyzed. The head muscles are 
thus used to diminish or correct the double vision. 

The character and degree of nystagmus are 
noted, if present, during these tests. 

V. Trifacial. — Disease of the nerve first shows 
itself in injury to the sense of touch. The presence 
of the sense of contact and the ability to localize 
objects on the skin are the only points tested. 
Two pieces of cotton-wool are applied simultane- 
ously to corresponding parts of both sides of the 
patient's face in the three areas of distribution 
(forehead, cheek-bone, and chin). The patient's 
eyes are, of course, closed. He is required to tell 
how many times he is touched, whether the two 
were on one or both sides of the face, and to name 
the portion touched. In the case of correct an- 
swers, he is to put his finger on the spots touched. 
When this test shows diminished or lost sensi- 
bility, the sensitiveness of the conjunctiva and 
the tongue is tested by a camePs-hair brush. The 
irritability of the mucous membrane of the nose 
is tested by snuff or ammonia. A complete sen- 
sory examination (for details see " Sensory Ex- 



12 METHODS OF EXAMINATION 

amination ") is to be made in case any alteration 
of touch is found. 

It is well to examine the sense of taste at this 
point, because any abnormality is considered as a 
disease of the fifth nerve. Sugar, citric acid, salt, 
and quinine are representative substances that 
produce the four tastes — sweet, sour, salty, and 
bitter — without arousing the sense of flavor (that 
is of smell). Bitter and sweet are tested at the 
back of the tongue; sour and salt at the tip and 
edges. The tests are not to be confined to minute 
areas, as there are spots that perceive one taste 
and not another. Taste is more acute in the 
young than in the old; individuals differ greatly. 
The test substances are employed in the form of 
solids, as their action can be more readily limited. 
The powder is employed with light friction and a 
short time allowed for it to dissolve. The tongue 
is kept protruded. The patient gives a signal as 
soon as he perceives a taste. 

A constant electric current furnishes the most 
accurate test for the nerve of taste, because it acts 
directly on the nerve endings. Two insulated 
wires with their points a few millimeters apart 
are connected to one or two galvanic cells; such 
a current (of two or three volts) is sufficient to 
arouse the sense of taste in normal conditions; 



IN NEUROLOGICAL DIAGNOSIS 13 

a stronger current would cause pain and obscure 
the result. This method should be employed 
specially to test the three regions : front and back 
of the tongue and the palate, when fracture of the 
base of the skull involving the chorda tympani is 
suspected. 

By placing the fingers on the masseter and 
temporal muscles of both sides and requesting 
the patient to bite forcibly, it is possible to recog- 
nize feebleness or absence of contraction resulting 
from affection of the motor branch of the fifth 
nerve. When the injury is slight, the affected 
muscle may contract a little slower and later. 

Inability to move the jaw toward the unaffected 
side, and deviation toward the paralyzed side 
when the jaw is depressed, indicate paralysis of 
the external pterygoids. Inability to thrust the 
lower jaw forward indicates paralysis of the in- 
ternal pterygoids. When the loss of power is only 
slight, it may be disclosed by opposing any of these 
movements. The downward movement of the 
jaw may be somewhat limited in cases of atrophy 
and secondary shortening of the paralyzed muscles 
of mastication. 

Any trophy or spasmodic disorders should be 
noted. Painful points and areas of pain-radia- 
tion are found in neuralgic states of either func- 



14 METHODS OF EXAMINATION 

tional or organic basis. When there is loss of 
masticatory power, unilateral furring and accumu- 
lation of food in the cheek may occur on the 
weakened or anaesthetic side. 

VII. Facial. — Since this is the motor nerve 
of the face and is involved in all voluntary acts 
and emotional expressions, the patient is required 
to perform such actions as elevating the eye- 
brows, frowning, closing the eyes firmly, showing 
the teeth, whistling, puffing the cheeks, and smil- 
ing. Voluntary and emotional acts may show 
differences. Unilateral loss of muscular tone 
shows itself in comparison of the two sides during 
rest. In cases of facial paralysis there may be 
secondary overaction after partial voluntary power 
returns; this defect may be seen during rest; it 
is intensified by slight movements and becomes 
marked during more forcible ones. When the 
patient closes the eye in strong contraction, the 
zygomatici on the paralyzed side will overact. 
This associated overaction may also be excited 
by reflex action through the fifth nerve (Chvostek's 
reflex). Any spasm present should be studied in 
regard to character and degree, during rest, vol- 
untary and emotional movements. The differ- 
ence in the voluntary movements of the lower part 
of the face, as in hemiplegics, for example, is 



IN NEUROLOGICAL DIAGNOSIS 15 

tested by having the patient raise the upper lip 
and move the mouth from side to side, when the 
unilateral defect will be obvious. Defect in emo- 
tional movements is seen in a smile, while the 
presence of an associated movement in the defec- 
tive side is obtained by causing the patient to 
grasp strongly with the sound hand. One may 
detect whether the wide open eye in the early 
stage of hemiplegia is peripheral or central palsy 
by noting, under test, whether the emotional as 
well as voluntary movement of hemiplegic defect 
is lost. 

VIII. Acoustic. — In order to exclude the fre- 
quent troubles due to disease of the ear, an ear 
examination has to be made. All impacted wax 
should be removed from the external meatus. 
To test the hearing the patient, with closed eyes, 
is required to say when he first hears the ticking 
of a watch that is gradually brought nearer his 
ear, or first loses the sound as the watch is moved 
away. A tuning fork may also be used. If there 
is no hearing in the ordinary way, the watch may 
be heard on touching it to the ear. If there is 
no hearing through the external ear, the watch 
or fork may be placed over the zygoma, mastoid 
process, or at the base of the nose. Slight defect 
in the meatus or middle ear is indicated when the 



16 METHODS OF EXAMINATION 

sound is heard longer by bone conduction than 
by air transmission; this is tested as follows: 
when the sound is no longer heard from the fork 
held close to and opposite the ear, it is at once 
placed against the mastoid process; normally, the 
sound will be still heard, although the vibrations 
of the fork are steadily decreasing. 

When the external meatus is closed during the 
test by bone conduction, the sound from the fork 
is intensified normally; when this does not occur, 
lowered conductivity of the labyrinth is indicated. 
The patient often fails in this test through in- 
ability to observe. Galton's whistle may be used 
to test nerve deafness, as its sound is shrill and 
short. Deafness to all its sounds is pathological. 
The watch may also be used. The test is carried 
out as follows: the antitragus is pressed over the 
external meatus. The watch is held near the 
mastoid or zygoma, but not against it. After a 
moment it is pressed firmly against a bone. If 
the watch is heard better in contact than when not 
in contact, the labyrinth is intact. If it is not 
heard better, the experiment is repeated with the 
tuning fork. If it is heard more faintly, this may 
be due to anchylosis of the stapes. No disease 
of the middle ear will entirely abolish bone con- 
duction. Failure to hear the watch by bone con- 



IN NEUROLOGICAL DIAGNOSIS 17 

duction often occurs after fifty years of age, yet 
there may be no other evidence of impaired nerve 
function; labyrinthine changes due to age are 
the cause. Bone deafness is normally rare in the 
first half of life. Bilateral deafness to Galton's 
whistle by air-transmission even in advanced life 
is pathological. In bone conduction the vibra- 
tions pass directly through the bone to the laby- 
rinth; the test is therefore one that excludes the 
conducting medium, the meatus and the middle 
ear, and serves to indicate the functional state of 
the internal ear. The perversions and elabora- 
tions of simple sounds into definite words are 
usually symptoms of insanity or epilepsy. 

Electrical tests of hearing produce vertigo and 
should not be employed. Their results are vari- 
able; they do not always aid in differentiating 
diseases of middle ear and nerve. 

There are no tests that can be applied to laby- 
rinth and nerve separately; the associated symp- 
toms can be used for differentiation. 

If the low notes of the Galton whistle are heard 
with undue loudness (hyperacusis), the stapedius 
muscle may be assumed to be paralyzed by disease. 

If pulsating sounds are heard, their frequency 
should be noted. When they are synchronous 
with the pulse and can be modified or suppressed 



18 METHODS OF EXAMINATION 

by compression of the carotids, they are vas- 
cular. 

IX. Glosso-pharyngeal. — The patient is made 
to swallow liquids. Regurgitation through the 
nose shows imperfect action of the upper muscles 
of the pharynx, and consequently paralysis or 
weakening of this nerve. Loss of the pharyngeal 
reflex to tickling indicates loss of sensibility of the 
superior pharynx. Unilateral impairment of this 
nerve is of little importance; there are no tests 
for detecting it. 

X. Vagus and Accessory. — For practical pur- 
poses the tests are confined to the muscles of the 
pharynx, larynx, thorax, heart, and gastrointes- 
tinal tract. 

Inability to swallow indicates paralysis of the 
pharyngeal muscles. Slight disability indicates a 
unilateral affection of the nerves or some physical 
obstruction. 

Paralysis of the larynx shows itself in changes or 
even loss of the voice. Coughing may arise from 
hindrance to inspiration or defective closure of 
the glottis. Laryngoscopic examination may 
reveal defective movements. Absence of vocal 
sounds with stridor or deep inspiration indicates 
complete paralysis. 

When the ordinary explosive cough is changed 






IN NEUROLOGICAL DIAGNOSIS 19 

to a sudden rush of air through the glottis, com- 
plete bilateral paralysis is indicated. When the 
voice is low-pitched and hoarse, one cord is usu- 
ally unaffected. With slight bilateral paralysis 
the cords can be used in phonation and cough, 
while deep inspiration produces stridor; there 
is no expiratory stridor, although expiration is 
shorter than inspiration. Tracheal stenosis does 
not produce so much movement of the larynx as 
does laryngeal paralysis. The presence of these 
symptoms makes a positive diagnosis of laryngeal 
paralysis possible. They may be slight or absent 
in unilateral affection of the cords; laryngoscopy 
examination is then necessary. 

Hysterical adduction palsy is always bilateral. 
Speech is not affected; expiration is noiseless; 
inspiratory stridor may occur. A differential di- 
agnosis from spasm of the glottis is thus rendered 
possible. Hysterical aphonia shows itself as paral- 
ysis of the adductors; the patient can cough but 
cannot speak; he can usually sing but he cannot 
whisper. Organic palsy shows itself in a less 
explosive form of cough; serious bilateral palsy 
is suggested in entire loss of cough and voice; 
loss of phonation without loss of speech indicates 
adduction palsy of minor import. Paralysis of 
one cord is indicated by loss of cough without 



20 METHODS OF EXAMINATION 

loss of voice. The routine of examination in a 
case of suspected laryngeal paralysis may well 
proceed according to the following scheme : — 

Symptoms Lesion 

No voice ; no cough ; stri- 
dor only on deep inspira- 
tion = Total bilateral palsy. 

Voice low-pitched and 
hoarse; no cough; stri- 
dor absent or slight on 
deep breathing = Total unilateral palsy. 

Voice little changed ; 
cough normal, inspira- 
tion difficult and long 
with loud stridor = Total abductor palsy. 

Symptoms inconclusive ; 
little affection of voice 
or cough = Unilateral abductor palsy. 

No voice; perfect cough; 
no stridor or dyspnoea = Abductor palsy. 

The examination for pulmonary, cardiac, and 
gastric symptoms of lesions of the tenth nerve 
should be preceded by search for diseases of the 
organs themselves. It is only when such organic 
lesions are absent that the symptoms can be used 
for conclusions concerning the nerve itself. Dis- 
ease of the nerve shows itself more or less positively 



IN NEUROLOGICAL DIAGNOSIS 21 

in retarded respiration, accelerated or retarded 
action of the heart, and vomiting. The way in 
which the symptoms are distributed and the dis- 
turbances associated with them will point out 
which portion of the vagus is diseased ; the roots 
and branches are most frequently affected. 

XI. Spinal Accessory (Spinal Portion), — Le- 
sions of this nerve show themselves most markedly 
in paralysis of the sterno-mastoid, the trapezius, 
and the elevation of the palate. When the sterno- 
mastoid is affected it loses its regular prominence 
in the contour of the neck when the head is moved 
from side to side. The degree of weakening can 
be estimated by opposing this side movement. 
If only one nerve is affected (unilateral paralysis), 
the defect in rotation is to the opposite side. In 
a condition of rest there is no deviation of the 
head in cases of unilateral paralysis unless the oppo- 
site muscle produces it by secondary contraction. 

To examine the trapezius, the examiner tells the 
patient to straighten the shoulders while he 
strives to hinder him from doing so. Complete 
paralysis and wasting show themselves at once to 
the eye. With unilateral paralysis the curves at 
the side of the neck will differ, producing an effect 
of asymmetry when the examiner stands directly 
in front or behind. The asymmetry appears most 



22 METHODS OF EXAMINATION 

markedly during deep respiration. When both 
sterno-mastoid and both trapezii are affected, the 
patient cannot maintain the head in upright posi- 
tion. If only both sterno-mastoids are involved, 
the head tends to fall back; if both trapezii, then 
it readily falls on the chest. Unilateral paralysis 
of both these muscles lets the head fall to one side 
or the other. Unilateral paralysis of the elevators 
of the velum is seen most clearly when the patient 
sings a long "ah" while the examiner looks into 
his mouth. 

XII. Hypoglossal. — The tongue should be ex- 
amined both while at rest and during protrusion. 
Unilateral paralysis shows itself by increased 
height on the affected side in the position of rest; 
this is due to the posterior fibres of the hypo- 
glossus. When the tongue is pressed into the 
cheek it can be overcome by the finger more 
easily on the paralyzed side. On protrusion the 
action of the unopposed genio-glossus deflects the 
tongue toward the paralyzed side. An imaginary 
line is drawn vertically between the two central 
incisors (the nose is often deflected from the me- 
dian line) ; the amount of deflection of the tongue 
is estimated from this line. 

In complete bilateral paralysis the tongue lies 
motionless and cannot be protruded. 



IN NEUROLOGICAL DIAGNOSIS 23 

It may happen that slight deflection of the 
tongue is noticed; this is not to be considered as 
indicating paralysis unless some other symptoms 
are found. 

Articulation, mastication, and deglutition are 
modified by bilateral palsy. Since the tongue is 
used to keep the food between the teeth, failure 
to do this is a convenient indication. The tongue 
also initiates the act of swallowing; the meaning 
of defective action here is also clear. 

Irregular longitudinal folds in the mucous mem- 
brane of the tongue — not " geographical tongue," 
a functional disease — indicate atrophy of the 
muscles. 

Defects of articulation are to be noted. The 
patient is required to pronounce certain letters. 
The occlusion sounds p and b are pronounced with 
lips tightly closed; paralysis of the lips makes it 
impossible to close them tightly, and these sounds 
become fricatives that resemble / and v. The 
occlusive sounds t and d are formed by pressing 
the tip of the tongue against the palate; in a case 
of paralysis the closure will be loosened and the 
two sounds will become th, as in "thin" and 
" thine." Other tongue sounds like I are also 
affected. When the soft palate is paralyzed, it 
cannot close off the nasal cavity from the mouth. 



24 METHODS OF EXAMINATION 

The sounds p and b require closure of the nasal 
cavity at the rear; when this does not occur, they 
become like m. For the same reason they lose 
their explosive character. 

With bulbar paralysis of milder type the patient 
enunciates all the consonants imperfectly; syl- 
lables are often run together or omitted. Some- 
times consonants are omitted or replaced by easier 
sounds or repeated. Special difficulty is found 
with r; a familiar phrase is " third riding artillery 
brigade." Other classical tests of paretic speech 
are " Peter Piper picked a peck of pickled peppers," 
" Massachusetts assurance security," etc. 

B. Trunk and Extremities 

General. — The examination is to be one of the 
condition of the muscles and the activity of the 
reflexes. The patient is to stand in the anatomi- 
cal position or to lie down. Unilateral lesions 
show themselves in differences between the two 
sides. Hypertrophy, due to use, may be present 
on the sound side; this must be allowed for in 
cases of unilateral lesion. The examiner should be 
trained to hold in mind a picture of the normal 
conditions, otherwise a bilateral lesion may escape 
notice. 



IN NEUROLOGICAL DIAGNOSIS 25 

Skeleton. — The development of the skeleton 
and its departures from the normal are noted, 
the standard being the normal condition for the 
patient's age, sex, and station in life. Deformities 
are looked for. 

Muscular Size. — The muscular examination is 
made by feeling the muscle at rest, in moderate 
contraction, and in strong contraction; its firm- 
ness, softness, etc., are noted. The degree of atro- 
phy or hypertrophy is also to be decided upon. 
The sizes of the muscles can be estimated by the 
eye if it has been well trained by the observation 
of normal cases. This makes it possible to dis- 
pense with comparative measurements. When 
such measurements are made they usually include 
the following: — 

Length of arm, from acromion to end of middle 
finger. 

Length of leg, from anterior superior spine of 
ilium to inner malleolus of ankle. 

Circumference of upper arm at largest part of 
biceps. 

Circumference of forearm at largest part just 
below the elbow. 

Circumference of wrist. 

Circumference of thigh at the gluteal fold. 

Circumference of thigh at its smallest part, just 
above knee. 



26 METHODS OF EXAMINATION 

Circumference of leg at the largest part, i.e. 
the calf. 

Circumference of leg at its smallest part just 
above ankle. 

A steel tape with automatic wind-up is used 
for these measurements, as its tension is uniform. 
Differences of one-half to three-quarters of an inch 
may be within the normal physiological varia- 
tions; they are not to be considered as pathologi- 
cal unless some other signs of disease are present. 
During the measurements the parts should be so 
held that the position in each one of the pair con- 
sidered should be the same; the tension should 
also be constant. All variations from the normal 
position should be noted. 

Muscular Power. — The examination should 
proceed systematically from the proximal to the 
distal parts of the extremity. The strength of con- 
traction in any case is best judged by resisting its 
action. Even in cases where no resistance is en- 
countered, the muscles may be sufficiently strong 
to move the limbs, particularly if gravity happens 
to aid. By placing the hand on the muscles in 
action the examiner can feel their character and 
firmness. The dynamometer is used to measure 
the power of the hand-grasp. It consists of a 
spring which opposes the closing of the hand. The 







Fig. 3. Testing the Grasp with the Dynamometer. 



IN NEUROLOGICAL DIAGNOSIS 27 

force exerted by the hand is automatically indi- 
cated on a dial. It is grasped in the hand and 
squeezed as hard as possible; care is to be taken 
that the arm is freely extended and that all arti- 
ficial support for the extremity is avoided. The 
ratio of 5 to 7 indicates the relation of power be- 
tween the right and left hands. This is reversed 
in left-handed people. Ordinarily it is sufficient 
for the examiner to have his hands grasped by the 
patient; he can then feel any difference between 
the two. He should give his right hand to the 
patient's right hand and his left to the left, just 
as in shaking hands; both should be done at the 
same time. 

Defects in segmental movements, such as that 
of adduction, abduction, flexion, and extension, 
should be looked for in examining for hemiplegia 
and similar cerebral diseases. The reason for this 
is that movements are represented in the brain and 
not muscles, as in the spinal cord. In diseases 
of the spinal cord, such as anterio-poliomyelitis, 
each muscle or group of muscles is examined sepa- 
rately. 

In cases of actual paralysis its range and com- 
pleteness, and also whether it is flaccid or spastic, 
are recorded. Inasmuch as the terms " paralysis" 
and " paresis" differ only in degree, by common 



28 METHODS OF EXAMINATION 

consent the term " paralysis" is now applied to all 
grades of the muscular deficiency and should be 
so used, subject to qualifications of degree and char- 
acter if so desired, in the case record. When the 
spastic paralysis is so strong that it cannot be over- 
come by ordinary effort the degree of permanent 
contracture is noted. " Positive contracture" is 
the term applied when the paralyzed muscles 
have shortened, as in old hemiplegias; " negative 
contracture" is employed when the unopposed 
muscular antagonists have produced the deformity, 
as in old spinal palsies. " Hypotonia" indicates 
a condition of diminished muscular tone, as in 
tabes; it appears in the extreme extension of the 
joints by passive means. One should test for 
varying degrees of flaccidity in the unconscious 
state of hemiplegia; thus the paralyzed limb, if 
raised, falls like a weight, influenced only by gravi- 
tation, while the normal limb falls less suddenly. 
Tremors. — Tremors are recorded as to their 
range (fine or coarse), their frequency (slow or 
fast), and their variations in regularity and equal- 
ity. The observations are to be made while the 
muscle is at rest, in simple and complex action, 
and under emotional excitement. For the for- 
mer case the limb or head should be rested on a 
support so that the muscles are fully relaxed. 



IN NEUROLOGICAL DIAGNOSIS 29 

The tremor can nearly always be seen if it is pres- 
ent. When it is very fine, it is sometimes neces- 
sary to touch the part in order to feel the tremor. 
To test for tremor in action, the extremity is vol- 
untarily raised or extended. This may make a 
tremor apparent or accentuate or diminish one 
already observed with the extremity at rest; a 
fine tremor may be changed to a coarse one. 

The fibrillary tremor is a special form; it consists 
in jerks of individual bundle-fibres, or of a wave- 
like contraction that attacks one bundle after 
another in quick succession so that the whole 
muscle is agitated as if a wave were going over it. 

Intention tremor (or action tremor) is a special 
condition which shows itself when the muscles 
are at increased tension; it is a quaking, coarse 
tremor that appears when the patient attempts 
to perform a voluntary act; it is observed specially 
in moving the arm. The usual test for bringing it 
out is to ask the patient to bring his index finger 
from behind him slowly to the point of his nose; 
if the action tremor is present, his arm wobbles 
around so that he can touch his nose only with 
difficulty. 

Spasm. — This is often apparent to the eye, but 
simple inspection furnishes often incomplete or 
defective knowledge. For accurate judgments the 






30 METHODS OF EXAMINATION 

hand is to be placed on the parts affected. The 
spasm may be tonic or clonic. It varies in degree 
of bodily movement, in range of muscle movement, 
in duration, and in rapidity. All these points are 
to be recorded. 

Spasm is frequent in disease of the spinal cord 
and its membranes. It may be tonic in character, 
which, when persistent, is designated as rigidity. 
Clonic spasm is usually transient and paroxysmal. 
Focal persistent tonic spasm causes distortion of 
the parts to which they are attached and induces 
what is known as contracture. The reverse of this 
condition is termed muscular hypotonia. 

Convulsions. — Transitory post-convulsive weak- 
ness should be especially noted, as it is a much 
more certain index of organic disease than the 
mere local commencement of spasm. The aura 
or premonitory sign, tonic or clonic spasm, degree 
and character of loss of consciousness, should be 
noted. The local commencement and order of 
muscular march in the Jacksonian fit should be 
recorded, as the place at which the sensation of 
movement begins points to the seat of instability 
in the brain. It is essential also to note whether 
there be a primary and secondary deviation of the 
eyes and head in the fit. If the head and eyes 
are turned first to one side and then later to the 



IN NEUROLOGICAL DIAGNOSIS 31 

other, it indicates a Jacksonian order of onset in 
the fit. 

Incoordination. — The test for the upper ex- 
tremities is to require the patient to touch suddenly 
with the finger or a pencil different parts of the 
body; this is done first with the eyes open and then 
with the eyes closed. The degree and the nature 
of the incoordination are noted. The direction 
of movements depends upon sensory elements. 
Incoordination interferes with voluntary move- 
ments, and vice versa. 

To test the incoordination in a lower extremity 
the patient is required to raise his leg while lying 
down. The ataxia shows itself in the fact that the 
leg is not raised directly vertically, but makes all 
sorts of movements — specially side movements 
— while being raised. In letting it down, it is 
not simply lowered, but is flung down violently 
in an unnatural position. 

Incoordination in the lower extremities is also 
tested by having the patient stand with his eyes 
closed and his feet close together. In mild cases 
he may be required to stand on one foot. Sway- 
ing forward and backward or from side to side 
occurs to a slight degree with all persons; a great 
many apparently normal persons sway a great deal. 
Neurasthenics may or may not do so. Incoordi- 



32 METHODS OF EXAMINATION 

nation due to disease produces considerable sway- 
ing; the patient may tend to fall or may even fall. 
This condition is known as " static ataxy," or 
Romberg's symptom. 

Another test for incoordination in the lower ex- 
tremities is carried out by having the patient walk 
to and fro ; he should also be called upon to 
" about-face" quickly. In milder cases he is 
required to walk a line or crack in the floor and 
to turn sharply around at command. Slight de- 
gree of defective equilibration is often shown only 
in the act of turning. The symptoms are usually 
increased if the patient walks with his eyes closed. 
In certain spinal cord affections there may be 
irregular movements when the guidance of vision 
is withdrawn and the base of support is rendered 
small by a juxtaposition of the feet. The delicacy 
of the test is further enhanced by having the pa- 
tient remove the firm base of support of the boot. 

In this connection it seems advisable to sum- 
marize the chief types of walking. The simple 
paretic walk arises from muscular weakness. It 
shows itself in slowness of the movements and 
shortening of the steps. The active movements of 
the legs are less extensive, but an excessive bending 
of the knees can occur. The partially paretic walk 
occurs when only single muscles or groups of 



IN NEUROLOGICAL DIAGNOSIS 33 

muscles are lamed. A particularly frequent and 
typical form occurs with paralysis of the peroneus. 
The foot of the swung leg falls downward. As the 
leg is thus lengthened the patient has to bend the 
extremity excessively at hip and knees. The foot 
makes two noises as it strikes the ground; the 
walk has been compared to that of a horse. The 
spastic paretic walk occurs when muscular stiffness 
is combined with weakness. Owing to the stiff- 
ness, the movement is slower and less exten- 
sive. The leg is moved somewhat as a whole. 
Specially characteristic is the scraping of the toe 
along the floor; this occurs because the contrac- 
tion of the muscles of the calf can be overcome 
only slowly and with difficulty. The pelvis is 
usually raised on the diseased side to compensate 
for the deficient flexibility of the leg. In extreme 
cases the toes remain on the floor and the pa- 
tient shoves them forward in short steps. If the 
adductors on the thighs are more powerful, the 
knees are rubbed together and the legs crossed. 
The ataxic walk has been described above. The 
cerebellar-ataxic form shows itself in two types, 
which may be combined: (1) one resting upon 
vertigo and disturbance of equilibrium, whereby 
the walk greatly resembles that of a drunken per- 
son; (2) another depending on ataxia, whereby 



34 METHODS OF EXAMINATION 

the patient walks with separated legs and stamping 
movement, but without any excessive swinging. 
In this case he stands with legs apart; we can 
observe continued jerks or momentary tensings 
of the foot- and toe-extensors. A sharp dis- 
tinction of this type from the spinal ataxic walk 
can be made only when type 1 is also present. 
The tremor walk occurs when every simple muscu- 
lar action is replaced by great tremors (multiple 
sclerosis, hysteria). Painful walks are of various 
kinds, according to the location of the pain. 

Trunk Muscles. — The examiner holds the finger 
at the level of the umbilicus and requests the 
patient to sit up. The umbilicus will rise one to 
three inches, according to the degree of paralysis 
of the rectus abdominis. 

Spine. — This is examined for deformity and 
tenderness. To determine tenderness lay the flat 
hand or the fist over the vertebra in which the 
disease is suspected, then strike this forcibly with 
the other fist. 

Reflexes. — Two kinds of reflex action are to be 
examined for. The first is that shown chiefly by 
stimulating the nerves of the skin. The second 
is produced by the stimulation of deeper nerves, 
chiefly those of the muscles. This latter form of 
reflex action is brought out, among other ways, 



IN NEUROLOGICAL DIAGNOSIS 35 

by tapping a tendon. The order of examination 
should be as follows: — 

Superficial Deep 

Conjunctival and corneal Pupillary 
Cilio-spinal Trigemino-facial 

Scapular Jaw- jerk 

Abdominal and epigastric Pectoral 
Cremasteric Elbow — biceps and triceps 

Gluteal Wrist — supinator and ul- 

nar 

Knee-jerks 

Achilles 

Front tap 

Babinski 

The following details concerning the method of 
carrying out the tests should be carefully noted. 
Careful examination of the loss of superficial re- 
flexes is sometimes of great importance, as their 
absence occurs often when the motor paralysis 
is slight. 

The skin reflex action may be caused at almost 
any part, but at some parts they are very definite 
in character and are in consequence given special 
names. There are many special skin reflexes. 
They vary in different individuals and are always 
more readily produced in the young than the old. 
They are increased and abolished by disease. 



36 METHODS OF EXAMINATION 

To test the conjunctival and corneal reflexes a 
twisted bit of cotton-wool is touched to the eye, 
contact with the eyebrows being carefully avoided. 

The cilio-spinal is tested by pinching the skin 
at the nape of the neck; the pupils should be seen 
to dilate. The skin reflexes are excited by gentle 
stimulation, as a light, quick or slow stroking of 
the skin rather than by a strong painful impres- 
sion. The reflex response is noted as quick, slow, or 
extensive, in proportion as they show the reaction 
to the stimulation, the nature of the reflex centre 
and its condition at the time of examination. Care 
should be exercised not to make too strong stimu- 
lation of the skin, as not infrequently a very wide 
reflex response may be caused, involving most of 
the muscles of the body, and thus obscure the very 
local response desired. As a rule, a painful im- 
pression causes quick flexion of the limb, such as 
may be necessary to withdraw the part from the 
cause of the pain; when withdrawal is impossible 
a protective movement results, as in case of the 
eyelids. The scapular is brought out by stroking 
the skin between the shoulder blades; the inner 
lower angles of the scapulae move toward the spine. 
The epigastric reflex is brought out by a quick, 
sharp stroke of the finger-nail or the end of a 
match along the free border of the ribs. Strok- 



IN NEUROLOGICAL DIAGNOSIS 37 

ing the hypogastrium brings out the hypogastric 
reflex. The cremasteric reflex consists in a sharp 
retraction of the testicle when a stroke is made 
along the inner side of the thigh. The gluteal 
reflex is produced by irritating the skin just above 
the gluteal fold. The plantar reflex is produced 
by stroking the sole of the foot; the foot is re- 
tracted. 

The deep reflexes are of greater clinical signifi- 
cance, and every precaution is to be taken to ex- 
clude error. 

To test the pupillary reflex the patient faces 
a window so that both eyes are equally lighted; 
the examiner alternately and conjointly exposes 
and screens the eyes with his hands. " Light ac- 
tion" is shown if the pupils respond by contracting 
and dilating; " light inaction" when they do not 
do so. To test the reaction of accommodation the 
patient is required to fix alternately a near and a 
distant object — both objects being equally lighted. 
If the pupils dilate and contract under the in- 
fluence of the different degrees of convergence, the 
result is recorded as l ' far and near action." When 
far and near action is present with light inaction 
the condition is known as the Argyll-Robertson 
pupil. 

To exclude confusion of the light test with that 



38 METHODS OF EXAMINATION 

for far and near action, the patient, in a dimly 
lighted room, may be required to definitely fix 
some point such as the examiner's nose; a match 
or a candle is then brought from behind the pa- 
tient's head to a position in front of the face so 
that the rays of light may fall upon the pupil. 
The reflected light from a mirror may also be used. 
This excludes pupillary accommodation to dis- 
tance. 

To show the jaw-jerh the finger is tapped while 
it depresses the lower jaw during slight muscular 
tension. 

To obtain the biceps-jerk the forearm is placed at 
a slight angle with the arm; a finger, which is laid 
on the biceps tendon, is tapped. A direct tap 
on the muscle tendon above the olecranon brings 
out the triceps-jerk; the arm is partly supported 
by the examiner, the forearm being allowed to 
hang loosely. To obtain the supinator- jerk a 
direct tap is made on the muscle midway between 
the elbow and wrist while the forearm is moder- 
ately flexed. The ulnar-jerk appears by striking 
the tendon of the extensor carpi ulnaris or the 
shaft of the ulnar bone where it becomes subcu- 
taneous. 

The most important muscular reflex is the knee- 
jerk. The knee to be tested is flexed nearly at a 




Ftg. 6. Method of Eliciting Biceps-jerk. 




Fig. 7. Method of Obtaining the Supinator-jerk. The Dotted Line 
indicates the Upward Jerk of the Hand in Reflex Response. 



IN NEUROLOGICAL DIAGNOSIS 39 

right angle by being placed over the other knee 
while the person sits. In this position the quad- 
riceps is gently extended. The patellar tendon is 
struck over the space above the tibia where it can 
yield if there is a sudden increase in the tension of 
the muscle. The quadriceps contracts and the 
lower leg is jerked forward. If the leg is too stout, 
the tension in this position may be too great to 
permit any movement. The examiner may place 
his arm beneath the patient's thigh just above the 
knee and rest his hand on the other knee. Posi- 
tions more favorable to muscular relaxation are 
sometimes found by letting the leg hang vertically 
or by resting the foot lightly on the floor. The 
contraction may be felt by the hand on the quadri- 
ceps. There should be no confusion between the 
recoil and the actual reflex movement. Attention 
to the leg leads to contraction of many of its 
muscles, whereby the reflex may be partly or 
wholly suppressed. Attention is diverted by 
having the patient hook his hands together and 
pull hard ; the eyes are closed ( Jendrassik) . The 
reflex is increased by being freed from opposing 
muscular contractions; such an increase is termed 
" reinforcement. " It is, in fact, necessary to 
guard against contraction of the flexors; precau- 
tions can be taken by feeling the hamstring ten- 



40 METHODS OF EXAMINATION 

dons; pressure on these often produces relaxation. 
The blow may be given with the side of the hand, 
the tips of the fingers, a percussion hammer, or 
a continental stethoscope with a rubber edge. 
When the jerk is doubtful the skin should be bared. 

The knee-jerk may be aroused by other means 
of suddenly increasing the muscular tension, espe- 
cially in condition of great excitability. It may 
be sufficient to strike a blow on the tibia. An- 
other way to excite the reflex is to jerk the patella 
downward while the patient is lying down with the 
muscles relaxed. This test can be made a very 
sensitive one by holding the patella down with a 
finger across the upper edge and then tapping this 
finger so as to suddenly increase the tension; the 
reflex is obtained even when there is only slightly 
increased excitability. If the tension is main- 
tained after the tap, repeated rhythmic jerks 
may be produced while the tension lasts in cases 
of great excitability of the muscle clonus. 

The Achilles reflex is aroused by gently pressing 
the foot up to increase the tension of the calf 
muscles and then tapping the tendon; the calf 
muscles contract and slightly extend the foot. 
The tap may be on the back or the side of the ten- 
don. If the foot is held so that it cannot yield, 
the contraction may be felt by the hand over the 







Fig. 10. Method of Eliciting the Knee-jerks simultane- 
ously. Dotted Line indicates the Degree of Unequal 
Response. 




Fig. 11. Usual Method of Testing for the Foot or Ankle Clonus. 




Fig. 12. Method of Testing Plantar Reflex, showing Extensor Response 
of the Great Toe (Babinski's Sign). 



IN NEUROLOGICAL DIAGNOSIS 41 

calf. The blow on the tendon does not cause the 
reflex directly; it suddenly increases the muscular 
tension and this arouses the contraction. Instead 
of a single reflex movement the blow may arouse 
a clonus (the ankle clonus) if the excitability of the 
calf muscles is excessive. 

To bring out the front tap reflex the tibialis 
anticus is smartly tapped with a hammer or stetho- 
scope while the foot is flexed dorsally by the exam- 
iner. The examiner holds the ankle on his knee 
or puts it on the edge of a stool slightly lower than 
the chair on which the patient sits; if the patient 
is in bed, the leg is extended. The foot responds 
to the tap by plantar flexion. 

Babinski's toe-reflex requires some care to ex- 
clude complications; the foot should be warm, and 
the leg should be partly flexed to aid the muscular 
relaxation and to avoid the occurrence of volun- 
tary movements. The thumb-nail or a match is 
stroked more or less slowly along the outer sole of 
the foot. Normally the big toe is flexed plantar- 
ward; if it is flexed dorsalward, or if the tendon 
of the flexor longus proprius is seen to flick up 
although no actual toe movement follows, the 
Babinski sign is present. Movements of the other 
toes — whether coinciding with that of the big toe 
or not — may be disregarded. 



42 METHODS OF EXAMINATION 

Electrical Examination. — The sponges must be 
kept moist by a weak solution of salt or baking 
soda. The indifferent electrode is put over the 
sternum, the sacrum, or the nape of the neck. 
The patient must completely relax the muscles. 
The exciting electrode must be small. Frequently 
less current passes during the first two or three 
applications of the shocks; the amount of current 
should be therefore always controlled by galvanom- 
eter readings. The intensity of the current must 
be the same in both cases, otherwise a polar change 
cannot be inferred. In the absence of definite 
polar change slowness of muscular contraction indi- 
cates slight R. D. in milder stages of nerve degen- 
eration. The less painful isolated induced shock 
is preferable for children and sensitive individuals. 
The examiner should in every case first test the 
current on himself, both for safety and also to 
minimize the patient's fear of the proposed test. 
The first test is to be made with the faradic cur- 
rent; if the reaction is normal, the galvanic test is 
unnecessary. If the response to faradism is di- 
minished or lost, galvanism may be employed for 
prognosis. The weakest galvanic current which 
will elicit a response is to be always employed. 
When the responses to both poles are slightly 
but equally diminished, the degree of abnormality 




Fig. 13. Method of Testing the Electric Response of 
Muscle (Supinator longus). 



IN NEUROLOGICAL DIAGNOSIS 43 

can be found by comparing the diseased side with 
the corresponding parts of the sound one; when 
the lesion is bilateral, an analogous part of a sound 
extremity may be used as a standard. When the 
test is negative to a current so strong that it can 
be borne without great pain, the response is said 
to be "lost." For practical purposes it is not 
necessary to try for the response that might still 
be gained in such cases under anaesthesia. The 
motor points of the face, arms, and legs are 
shown in Fig. 14 to Fig. 19 inclusive. 

Different individuals and different parts of the 
same individual show differing degrees of sensitive- 
ness of the skin. The resistance to the electrical 
current varies likewise, and the current must be 
increased when it is greater. The need of the 
galvanometer is evident. The current actually 
used should be known. When the patient's sen- 
sitiveness to pain prevents the use of this instru- 
ment in all measurements, it may be used once to 
gain information as to the significance of the num- 
ber of cells that constitute the evidence of the dif- 
ference between the two sides. In complete reac- 
tion of degeneration, percussion should be applied 
to the muscles to see if mechanical excitability is 
also present; it shows itself by slow muscular con- 



44 METHODS OF EXAMINATION 

traction in the part struck. The contraction of 
the muscle is continuous when the faradic current 
is applied; but if isolated shocks of this current are 
applied, brief, momentary contractions are caused. 
When voltaic current of moderate strength is 
applied, contraction occurs only when the current 
is changed in strength or when the current is 
"made" and "broken." In proportion as the 
nutrition of the nerve fibres is impaired, their ex- 
citability is lowered and a stronger current of each 
kind is required to excite them and cause contrac- 
tion in the muscles they supply. When there is 
doubt whether the voltaic current is acting through 
the nerve endings or on the muscle fibres them- 
selves in neuritis, the slow contraction and its 
longer duration proves the latter to be the case. 
Sometimes there is a slight abnormal tetanic con- 
traction during the passage of the current. Dur- 
ing the period of increased voltaic irritability the 
mechanical excitability of the fibres is often in- 
creased, and if they are percussed directly, they 
respond with a distinct, slow contraction. 

C. Sensoky Examination 

Touch. — In testing the sensibility of the ex- 
tremities one should examine circularly around the 




Fig. 14. A Diagram of the Motor Points of the Face, showing the 
Position of the Electrodes during Electrization of Special Muscles 
and Nerves. The Anode is supposed to be placed in the Mastoid 
Fossa, and the Cathode upon the Part indicated in the Diagram : 1, 
Occipito frontalis (ant. belly) ; 2, Corrugator supercilli; 3, Occi- 
pito frontalis (post, belly) ; 4, Orbicularis palpebrarum ; 5, Retra- 
hens and Attolens aurem; 6, Pyramidalis nasi ; 7, Facial nerve; 
8, Lev. lab. sup. et alae nasi ; 9, Stylo-hyoid ; 10, Lev. lab. sup. 
propr.; 11, Digastric; 12, Dilator naris ant.; 13, Buccal branches 
of facial nerve; 14, Dilator naris post.; 15, Subcutaneous branch 
of inferior maxillary nerve; 16, Zygomat. minor; 17, Splenius 
capitus; 18, Zygomat. major; 19, external branch of Spinal acces- 
sory nerve; 20, Orbicularis oris ; 21, Sterno-mastoid; 22, Branch 
for Levator menti and Dep. ang. oris; 23, Sterno-mastoid; 24, 
Levator menti ; 25, Levator anguli scapulae ; 26, Dep. lab. infer. ; 
27, Phrenic nerve ; 28, Dep. ang. oris ; 29, Posterior thoracic nerve 
to rhomboid muscles; 30, Subcutaneous nerves of neck; 31, Cir- 
cumflex nerve ; 32, Sterno-hyoid ; 33, Posterior thoracic nerve to 
Serratus magnus ; 34, Omo-hyoid ; 36, Sterno-thyroid ; 38, Branch 
for Platysma ; 40, Sterno-hyoid ; 42, Omo-hyoid ; 44, 46, Nerves to 
pectoral muscles. 



Deltoid (ant. half) 

mus.-cut. n. I 
Biceps { 
Median n. 

Brach. ant. 

Supinator long. 

Flexor carpi radialis 
Flex, digitor sublim. 

Flex. long, pollicis 

Median n. 

Adductor pollicis 

Opponens pollicis 

Flex. brev. pollicis 
Adductor pollicis 

Lumbricales 




& 




M 



y /" 



Triceps (long head) 

Triceps (inner head) 
Ulnar n. 

Pronator teres 

Flex, carpi ulnar. 
Flex. dig. profund. 

Flex. dig. sub. (II & III) 

Flex, digit, sub. (I & IV) 

Ulnar n. 

Palm. brev. 

Abd. minim, digit. 

Flex. min. dig. 
Oppon. min. dig. 



Fig. 15. Motor Points for the Arm, Inner Side. The Points at which the 
Muscles and Nerves can most Effectively be Stimulated. 



Deltoid (posterior half) 



Musc.-spiral n. 
Brachialis ant. 

Supinator Iongus 
Extensor radial, brev. 

Extensor digit. 

Extensor indicis 

Ext. os. met. pol. 
Sxtensor pr. intern, pol. 
Dorsal interossei 
(I and II) 




Triceps (long head) 
Triceps (outer head) 



Extensor radial, long. 
Extensor carpi uln. 

Supinat. brev. 

Extens. minim, digiti 
Extensor indicis 

}Extens. long. poll. 



Abduct, minim, digiti 
Dorsal interossei 
(III and IV) 



Fig. 16. Motor Points for the Arm, Outer Side. 




Fig. 17. 1, Tensor vaginae femoris (branch of supe- 
rior gluteal nerve); 2, Anterior crural nerve; 

3, Tensor vaginae femoris (branch of crural nerve) ; 

4, Obturator nerve ; 5, Rectus femoris ; 6, Sartorius ; 
7, Vastus externus ; 8, Adductor longus ; 9, Vastus 
externus; 10, Branch of crural nerve to Quadriceps 
extensor cruris; 12, Crureus; 14, Branch of crural 
nerve to Vastus externus. 



Ext. poplit. n. 

iGastrocnem. (outer head) 

Peroneus longus 



Soleus 
Peroneus brevis 

Flexor long, pollicis 



Extensor brev. digit 
Abductor minim, digit 




Tibialis anticus 
Extensor digit 



Extensor long. poll. 



Dorsal interossei 



Fig. 18. Motor Points of the Outer Side of the Leg. 



Gluteus maximus 

Sciatic n. 

Biceps (long head) 

Biceps (short head) 



Ext. poplit. n. 
Gastrocnem. (ext. head) 



Soleus 



Flexor long. poll. 




Adductor magnus 

Semitendinosus 
Semimemb ranc s us 



Int. poplit. n. 

Gastrocnem. (int. head) 
Soleus 

Flexor digit, comm. 
Tibial n. 



Fig. 19. Motor Points, Back of Thighs and Legs. 







Fig. 20. Sensory Areas of the Skin according to Head. Front View. 



IN NEUROLOGICAL DIAGNOSIS 45 

limb to note whether the disorder corresponds to 
spinal cord segments, which constitute the so- 
called spinal cord type of anaesthesia, or to the sen- 
sory defect of the cerebral type, sleeve- or glove- 
like anaesthesia, which is best revealed by testing 
sensation up and down the limb. 

Touch is tested by contact. It is change of 
contact that arouses sensation; prolonged, uni- 
form contact at one place is perceived only by 
close attention. Beginning contact is more effec- 
tive than its cessation. The effect of the change 
depends on its rapidity. A sudden touch is ob- 
served no matter how light it is; a firm pressure 
is scarcely noticed if it is gradually applied. The 
test for contact should be a pure one, not obscured 
by sensations of heat or cold. This is a defect in 
using the finger as a test object; cotton is there- 
fore employed. The patient, with closed eyes, is 
required to tell when he is touched. Points are 
touched irregularly over the skin and at irregular 
times. Sometimes the patient is asked if he feels 
a touch, when no application has been made; 
some patients are apt to have such illusions. The 
contact should not be too gentle. When the skin 
is thick, light contacts are often not felt even by 
normal persons. The examiner should try the 
tests on himself in order to regulate them. The 



46 METHODS OF EXAMINATION 

patient should be required to name the part 
touched and to localize it with the finger. The 
term " sensibility to touch" should be used instead 
of "anaesthesia," as the latter is often inaccurately 
used. One should always test sensation at the 
level of the cord lesion as well as that below, and 
remember that the " level of lesion" may involve 
either the limbs or trunk, or both. Anaesthetic 
areas may be found on the trunk when there are 
none on the limbs (spinal caries). 

Simple increase of the sense of touch is really 
due to a perversion of the sensation of touch. 
The sensation may be described as " thrilling" or 
"shocklike." In cases of extreme increase, touch 
may produce pain, but this symptom should be 
noted as a stimulation of the oversensitive nerves 
of common sensibility rather than pain due to a 
disturbance of the tactile nerves. Touch may 
cause pain when it is not appreciated as touch. 
In certain spinal cord diseases one finds impair- 
ment of pain and temperature with retained 
tactile sensibility (syringomyelia). Careful analy- 
sis and record should be made of the spontaneous 
sensations other than pain. Variations in these 
sensations are often indescribable, but the ob- 
server ought to try to elucidate their character 
without leading the patient. 




Fig. 21. Back View. 



IN NEUROLOGICAL DIAGNOSIS 47 

Another test of touch involves the smallest dis- 
tance at which two points applied to the skin can 
be felt as two. At a shorter distance apart they 
appear as one. Ordinary dividers with dulled 
points may be used; a more convenient "sesthe- 
siometer" is that of Sieveking, in which the points 
are attached to a graduated metal bar. The 
points must be applied to the skin simultaneously 
and with equal degree of pressure. The examina- 
tion requires time and patience. Practice gives 
the patient increased sensitiveness. The defect 
must be very marked in order to give results that 
are conclusive. The test is not as valuable as 
once supposed. 

The minimum distances at which two points can 
be distinguished are as follows: — 

Tip of tongue 1.5 min. 

Finger tips 2 to 3 min. 

Lips 4 to 5 min. 

Tip of nose 6 min. 

Cheeks and back of fingers 12 min. 

Forehead 22 min. 

Neck 34 min. 

Forearm, lower leg, back of foot ... 40 min. 

Chest 45 min. 

Back 60 min. 

Upper arm and thigh 75 min. 



48 METHODS OF EXAMINATION 

The distance is smallest at the tip of the tongue 
— that is, the sensitiveness is greatest. 

Different individuals show variations in the 
relations from those in the table; variations that 
are proportional all over the body are probably 
physiological. 

Pain. — The nerves of common sensibility carry 
the sensations of pain. The test is usually made 
with a blunt pin-point. A needle should not be 
used; its point is too fine. It may penetrate the 
skin. Moreover, it may not be felt at all where 
the nerve endings are not close together in case it 
happens to strike between them. The test may 
be made with a fine wire from a faradic battery, 
but the test must be made with great care and 
the current must be carefully graduated if accu- 
racy is to be gained over the pin-point method. 
Simple touch may produce pain if common sen- 
sitiveness is greatly increased. Sensations dis- 
tinctly abnormal, such as thrilling, tingling, etc., 
may be produced by both tactile and painful 
impressions. 

Sometimes the prick is perceived first as a touch 
and afterward as a pain (as in tabes). The 
patient may name only the first one; he should 
be required to name each as it appears. 

The fingers should grasp the pin so as to expose 




Fig. 22. Side View. The Mapped Skin Areas 
alternate with those shown in Fig. 23. 



IN NEUROLOGICAL DIAGNOSIS 49 

only a certain portion of the point; in this way 
the test is kept uniform. Sensitiveness to pain 
is often diminished but not lost. Frequent com- 
parisons to some standard in another part of the 
body should be made in order to avoid the source 
of error just mentioned, and also the errors arising 
from mistaken and varying notions of the patient 
as to the degree of pain which he should recognize. 
The disagreement and unreliability of many ex- 
aminations are to be largely attributed to those 
sources of error. 

Temperature. — Hot and cold spoons, or a 
hinged-tongue depressor with one blade heated, 
or two similar test-tubes with hot and cold water 
may be used. The degrees of heat and cold must 
be sufficiently marked to justify us in regarding 
the patient's doubt as pathological and not as 
due to lukewarmness of the testing object. To 
determine the power of differential discrimination 
large test-tubes containing thermometers are rilled 
with water of known temperatures. 

Temperature is usually affected together with 
sensibility to pain, but not often in the same 
degree; one may be impaired without the other, 
as in syringomyelia. This is different from the 
case with touch, where sensibility to pain may 
vary though touch is intact. There may be abso- 



50 METHODS OF EXAMINATION 

lute loss to both heat and cold. Slight diminu- 
tion in the sensitiveness to temperature may pass 
undetected. 

Although in some cases considerable degrees 
of difference are correctly felt, a quality of differ- 
ence may be perceived analogous to that noted 
in the perception of difference of pressure. Hot 
objects may feel cold, and vice versa. Objects of 
ordinary temperature may arouse sensations of 
pain, or heat may be less readily perceived than 
usual. Delay in the perception of temperature is 
found in the cases where such a delay in the percep- 
tion of a pin prick occurs. Normally, temperature 
is less quickly perceived than pain, because time 
is required to raise the temperature of the skin suf- 
ficiently to enable the heat to penetrate its nerves. 

The accuracy of the test of the pain sense may 
be verified in a rough way by a test-tube with 
water hot enough to produce pain normally. 

The examination for each of the two senses, 
heat and cold, should be kept separate, because 
the nerves for the two are different; the nerve 
endings are distributed differently over the skin. 
One set of spots feels heat, another set, cold. 

Figures 20 to 23 inclusive give the sensory areas 
corresponding to the various segments of the 
spinal cord. 

Muscle Sense. — This includes also muscle-pain 




Fig. 23. Side View. 



IN NEUROLOGICAL DIAGNOSIS 51 

sense. To test the sensations from the muscle 
fibres the belly of the muscle is gripped; the un- 
comfortable or painful sensations are compared 
with similar sensations from muscles known as 
sound. Postural sense is a compound of sensa- 
tions from the skin, joints, and muscles; it is 
tested by the parts while at rest or in action. 
Resistance to contraction is tested as follows: 
the patient, with closed eyes, tries to detect dif- 
ferences in weight between pairs of objects, such 
as leather balls the size of golf balls weighted to 
degrees between two drachms and two pounds. 
The skin furnishes part of the sensations in this 
test, but this complication can be diminished by 
placing the weight in a bag suspended by a string 
from the part tested ; or increase the area of the 
suspension in order to diffuse the skin impression 
in a diminished degree over a large area; or in- 
crease the weight and therefore the pressure 
in both area and degree so that the addition to 
be discovered shall bear only a small proportion 
to the total. A difference of one-fortieth may be 
distinguished by the muscle sense; the skin has 
a much duller sensibility. It is not practical to 
apply an electrical test to the skin. Application 
to the muscle is possible only after anaesthetizing 
the skin by cocaine. 



52 METHODS OF EXAMINATION 

The ability to recognize passive posture is a 
rough but practical test for muscular sensibility. 
The patient's eyes are closed. A limb is seized 
by the examiner and placed in some position. 
The patient tells the position or places the limb 
of the other side in the corresponding position, 
or indicates the direction of the movement with 
the fingers. If the skin is normally sensitive, the 
examiner should take care to grasp the limb 
firmly and press on both sides so that the posture 
may not be judged by the direction of pressure. 
The examination should be repeated several times 
to avoid error. 

Outline figures are made specially for charting 
the data concerning touch, pain, and temperature. 
See Figs. 24 and 25. This is far better than 
written descriptions, which are too confusing and 
obscure for rapid reference. 

The astereognostic sense is that which recog- 
nizes form. It is tested by applying to the skin 
or giving in the hand of the patient with closed 
eyes such objects as keys, coins, etc., and asking 
him to describe their size, weight, and form. 

D. General Functions and Viscera 

Aphasia. — This is the term applied to a speech 
defect that is not articulatory. It must be tested 
in such a way as to show its exact nature. Motor 



IN NEUROLOGICAL DIAGNOSIS 53 

memory, visual memory, and auditory memory 
are involved. The patient's ability in speaking 
voluntarily and in repeating words spoken by 
some one else makes it possible to draw conclu- 
sions concerning his motor-speech centre and its 
association tracts. His visual memory is in- 
volved in his capacity to understand written or 
printed words; to write spontaneously; to write 
common things he sees (such as knife, button, etc.), 
which he hears, or which he touches; to copy writ- 
ing; to understand written directions as shown 
by his ability to execute them. The integrity of 
auditory speech and its association is shown in the 
power of the patient to recall names of familiar 
objects seen, heard, touched, etc.; to understand 
ordinary speech, and to recognize musical airs 
(whistling Star-Spangled Banner, for example). 

Vaso-motor and Trophic Disorders. — Ulcers, 
nutrition of skin, hair, nails, changes in color and 
heat of skin in different parts of the body — all 
these are signs that may be used in looking for 
vaso-motor and trophic disorders. A thorough 
visceral examination of the blood, urine, tempera- 
ture, pulse, etc., is to be made ; in addition to this 
the condition of the sphincter is to be specially 
noted in spinal affections. Three different con- 
ditions appear in urinary incontinence: (1) low- 



54 METHODS OF EXAMINATION 

ered cerebral function, as in tumor cases where 
neglect of the personal toilet leads to retention 
and final overflow; (2) paralysis of the sphincter, 
as in spinal paralysis; (3) mental defect, as seen 
in idiocy. 

The following composite case-record is given to 
show how the facts elicited in the previous ex- 
amination of the patient should be arranged : — 

Exam. Oct. 1, 1907. William Johnson, 36, s., Eng., in 
U. S. 10 yrs. 

Diagnosis: Tabes Dorsalis 

Compl. of. — Sharp pains in legs and inability to walk 

in the dark. Duration, 3 yrs. 
F. H. — P. Gf . d. insane, 53. M. Gm. 1. and w., 82. P. 

g. uncle Bright 's. 2d cousin imbecile and F. d. 43, 

ale. and tobacco. M. 1. and w., 60. 1. (Boy) 26 

(our pt.). 2. (Girl) 23, insane (dementia) (D. P. ?). 

3. (Boy) epileptic from 8 yrs. 4. (Girl) 14, 1. and 

w. Neurotic. 
P. H. — Full term ; 1. normal but difficult, prolonged 

(18 hrs.), instrument. Artificially fed. 2 convul. 

at dentition. Measles at 3. Scarlet f. at 6. Rt. 

otitis m. Puberty, somnambulism 1 yr. School 

C. S. until 16. Fairly competent journeyman 

barber; always lived in N. Y. ; married at 22; 

3 child., 12, 8, and 6; all 1. and w.; wife no misc. 

Ale. and tobacco to excess. Gonorrhoea at 18. S. 



IN NEUROLOGICAL DIAGNOSIS 55 

denied, but exposure admitted (20-24). Typhoid 
40. Constipated 10 yrs. 

P. I. — One year ago (Oct., 1904), dull paroxysmal head- 
aches appeared suddenly without cause, most local- 
ized over right occiput; afternoons at first, then 
(3 mos. after) constant. Scalp tender to mild press- 
ure; pain from headache radiated into right neck 
and shoulder muscles, marked stiffness and rigidity 
of the same; vomiting on rising in the morning 
almost daily during last 8 mos.; for 9 mos. a 
very unsteady gait ; diplopia for 10 mos. at times 
corrected by prisms ; some failure of eyesight past 
4 mos. 

P. C. — Well built, muscular, blond, German. Looks 
his age (36) ; appears rather depressed and dazed ; 
walks with uncertain, reeling gait; tendency to 
walk to the right; eyes to floor; quite anaemic. 

Motor, Sensory, and Special Sense 

Cranial Nerves. 
1. — Detects odors but poorly. Chronic catarrhal 
rhinitis for 6 yrs. 

2. — Rv. 20/20. Lv. 8/20. Vis. fs. contracted; rt. to 

30°, It. contracted to 0°. L. O. D. congest, swelling 
i d. Disk margin hazy. Central oedema. Few 
hemorrhages. R. O. D. hazy disk margin, nasal ; 
temporal pallor. 

3. — 3, 4, and 6 ext. rectus weak, sec. deviation, errone- 

ous project. 2 in., intermit, diplopia, corrected by 
prisms. 
5. — Painful (sensitive to touch) in entire skin area 
(see chart) ; exquisite radiating pains on pressure 



56 METHODS OF EXAMINATION 

at first and second foraminal openings; vaso- 
motor paresis marked; no motor changes; no 
taste changes. 

7. — Rt. normal. Lt. entire palsy, most about eye. 

Complete R. D. 

8. — Rt. = watch at 6". Lt. = bone conduction only 

(labyrinthine disease) . 

9. — Liquids regurgitated through nose. 

10. — Slight difficulty in completing act of swallowing. 

Resp. normal. 

11. — Rt. sterno-cleido mastoid weak. 

12. — Increased height to tongue in retraction, weak 

in left cheek; protruded, but deviates to right; 
articulation indistinct; first act of swallowing 
defective. 

Upper Extrem. 

(Motor) Scapula and Shoulder Joint 

R. L. 

Trapezius 

Rhomboids 

Levator ang. scap weak 

Serratus mag slightly weak .... 

Deltoid .... no action, atrophy marked . 

Supraspinatus paralyzed .... 

Infraspinatus . . . paralyzed and atrophied . . 

Teres minor 

Subscapularis 

Latissimus dorsi 

Pect oralis major . . . slight contract ... 

Pect. minor 

Teres major slight contract ... 



IN NEUROLOGICAL DIAGNOSIS 57 

Muscles of Forearm and Hand 

R. L. 

Triceps 

Br. anticus weak 

Biceps . . . . marked atrophy, very weak . 

Sup. longus 

Sup. brevis no action .... 

Pronators 

Fl. of wrist 

Ext. of wrist weak 

Fl. of fingers contract .... 

Ext. of fingers 

Summary. — Weakness or paralysis and atrophy in 
supra- and infra-spinatus, deltoid, biceps, br. 
anticus, supinator brevis (Erb's palsy distribu- 
tion) . 
Scapula and whole arm dwarfed; internal rotation 
of humerus; contracture-deformity at shoulder joint, 
elbow, and wrist. Internal rotators of rt. humerus in 
negative contract; may be partly overcome. Flexors 
of wrist in same condition of contracture. 



Dynam. . . . 
Length of arm 
Length of humerus 
Cir. of arm . . 
Cir. of forearm . 
Cor. of wrist . . 



Comparative Measurements 

R. L. 

33" 60" 

21" 23" 



iif" ±^r 

10" 10f" 

10}" 10J" 

7// 74// 



58 METHODS OF EXAMINATION 

Measurements show atrophy and shortening largely 
in rt. shoulder and arm. 

Trunk and Lower Ext. — Normal musculature in all 

movements; no atrophies. 
(From a Case of Right Hemiplegia of Two Weeks' 
Duration.) 

Reflexes 

Superficial 

R. L. 

Conjunc absent 

Corneal diminished .... 

Cilio-spinal weak 

Scapular absent 

Abdom absent 

Epigastric . absent 

Cremasteric absent 

Plantar weak 

Deep 

R. L. 

Pupillary 

Trigem.-facial . . 

Jaw-jerk 

Pectoral exag 

Triceps exag 

Biceps exag 

Supinator . . exag 

Ulnar exag 

Knee-jerks exag 

Achilles jerk exag 

Front tap exag 

Babinski present 

(From a Case of Ant.-Polio. M.) 




=Hyperalgesia 

= Ana?sthesia 

******** _ Muscular 
x.iTww ~~ Weakness 

»°o °°o° ° = Raised 
00000 Temperature 



Fig. 24. Figure showing Meth- 
od of Charting Areas of 
Anaesthesia, Hyperalgesia, 
Muscle Weakness, and Dis- 
turbance of Temperature. 
(Brown -Sequard Paralysis 
after a Lesion at the Eleventh 
Dorsal Segment.) Front View. 




Fig. 25. Figure showing 
Method of Charting Areas 
of Anaesthesia, Hyperalgesia, 
Muscle Weakness, and Dis- 
turbance of Temperature. 
Same Lesion as in Fig. 24. 
Back View. 



IN NEUROLOGICAL DIAGNOSIS 59 

Elect. Ex. — Rt. Ant. tibial = R. D. partial. 

Rt. Ext. peroneal group = R. D. complete. 
Sensory Ex. — Touch. 
Pain. 
Temp. 

Muscle sense. 
Muscle-pain sense. 
(From Case of Unilateral Crush of Cord D. 11'. See 
Chart, for manner of charting sensory data. Figs. 
24 and 25.) 
On side of lesion: Skin hyperesthesia D. 11". 
Muscle sense impaired. 
Temp, slightly raised D. 11". 
On opposite side to 

lesion: Loss of sensibility D. 11". 

Muscle sense normal. 
Temp, normal. 
(From a Case of Right Hemiplegia in a Woman.) 

Disorder of General Function (Organ. Reflex) ; Visceral 
Ex. : — 

Partial motor aphasia. 

Repeats words slowly and imperfectly. 

Asthmatic; temp. 99° F., pulse 74, normal. 

Rectal and vaginal ex. neg. 

Mitral regurg. ; severe arterial sclerosis. 

Urine normal; blood not exam. 

Weight, 93 lbs. ; height, 5 ft. 6 in. 

Vaso-motor and trophic disorders. 

Ulcer on rt. buttock (pt. bed-ridden). 

Skin dry and scaly, hair and nails brittle on rt. 

Blueness and coldness of exts. on rt. side. 



60 



METHODS OF EXAMINATION 



The first page of the history blank should be 
reserved for a short synopsis of the chief symptoms 
upon which the diagnosis rests. It may be ar- 
ranged as an epitome of the complete record 
detailed here at length. 



Part II 
CHAPTER I 

Part II of the book is designed to aid the 
student and practitioner in making and recording 
examinations of insane patients and in acquaint- 
ing themselves with the more common forms of 
insanity. There is described first the method of 
taking the history and the method of making the 
neurological and mental examinations. Specimen 
cases are then given which demonstrate these 
methods and give an insight into the more com- 
mon forms of insanity. At the end is appended a 
glossary of the common terms used in psychiatry. 

In mental disease it is of the utmost importance 
that the student employ a definite routine method 
of examination of the patient. Any method to 
be satisfactory must include (a) the anamnesis of 
the family, (6) personal history previous to the 
disease, (c) the anamnesis of the disease, and 
finally (d) the status praesens. 

(a) The importance of heredity as an etiological 
factor necessitates a careful consideration of the 

61 



62 METHODS OF EXAMINATION 

family history, not only as regards the presence 
of mental and nervous diseases, but also evi- 
dences of defective physical constitution. This 
can never be elicited by simply asking the general 
question if there is a history of insanity or nervous 
diseases in the family, but it requires a detailed 
inquiry into the habits, traits, and physical ill- 
nesses of all the members of the direct branches of 
the family, laying particular stress upon mental 
peculiarities, alcoholic and other addictions, and 
criminal tendencies. 

(b) The personal history should begin with an 
inquiry into the conditions attending gestation 
and birth, such as exhausting diseases, depriva- 
tion, severe emotional shocks, mental anguish, and 
birth trauma. In infancy, there is the presence 
of infectious diseases and their sequelae, convul- 
sions, head injury, paralyses, and the tardy appear- 
ance of walking and talking, and in childhood the 
progress in school and conditions accompanying 
puberty and menstruation, also the existence of 
masturbation, sexual impulses, peculiar emotional 
manifestations, timidity, morbid temperaments, 
religious experiences, etc. If married, the con- 
ditions attending child-bearing should be known, 
as well as severe illnesses, such as typhoid fever, 
injuries, mental shocks, and deprivation; and if 



IN MENTAL DIAGNOSIS 63 

employed, the character of the work, the materials 
handled, the sanitation and undue physical and 
mental strain, excessive indulgence in eating, 
drinking, and amusement, and also drug habitua- 
tion. Personal idiosyncrasies, exaggerated ego- 
tism, one-sided intellectual development, with 
attainments in one field and lack of development 
in another, should be included in your list of in- 
quiries. In eliciting such facts it should be borne 
in mind that general questions are wholly inadequate. 
It requires close and detailed questioning, and 
even then important facts are very apt to be 
overlooked. 

In determining the cause of the disease, one 
should guard against mistaking for causes the 
actual early symptoms of disease, such as the 
excesses of the paretic, the self-condemnation of 
the melancholiac, and the masturbation of the 
hebephrenic. 

(c) In eliciting the anamnesis of the disease , par- 
ticular attention should be paid to the character 
of the onset and the symptoms to date. In secur- 
ing this information it is usually most satisfactory 
to follow the outline prescribed for making a 
mental status (see (d) below), i.e. elicit informa- 
tion concerning the presence of hallucinations or 
illusions, of disorders of apprehension, attention, 



64 METHODS OF EXAMINATION 

memory, orientation, train of thought, judg- 
ment, and in the emotional and volitional fields 
at various stages in the development of the 
disease. 

It is often difficult to determine the actual date 
of onset of the disease because the initial change 
in disposition is sometimes so insidious that the 
true significance of certain peculiarities is not 
appreciated until emphasized later by the occur- 
rence of the more striking symptoms. In case 
there have been one or more previous attacks of 
mental disease, there should be the same careful 
inquiry not only into the character of the symp- 
toms presented at these periods and their dura- 
tion, but also particularly as to whether the patient 
fully recovered or suffered residual defects in some 
field of the mental life. 

(d) Status Praesens. — This examination should 
include observations of both the physical and 
mental condition of the patient. In view of the 
fact that many persons are particularly sensitive 
about undergoing a mental examination, it is 
desirable to begin with the physical examination. 
During it there is always opportunity to frame 
questions in such a way that the answers will give 
valuable information as to the mental state; as, 
for instance, the memory can be determined by 



IN MENTAL DIAGNOSIS 65 

questions as to the date of appearance of certain 
physical signs, or the orientation may be ascer- 
tained by questions as to those who are caring for 
them, by whom their food is prepared, etc. In- 
deed, the great variety of physical symptoms to 
be inquired into offers sufficient chance to cover 
all fields of the mental status; even hallucinations 
and illusions of hearing and sight may be dis- 
closed during the examination of the senses of 
hearing and sight. 

The general survey of the body should include 
the state of nutrition, the present body weight 
compared with earlier weights, the presence of 
anaemia or cachexia, signs of premature senility 
or delayed pubescence, also evidences of so-called 
physical stigmata, as harelip, malformation of the 
palate, of the ears or sexual organs, albinism, 
congenital strabismus, malposition of the teeth 
and eyes, etc. Trauma, scars, and residuals of 
previous diseases should not be overlooked, and 
particularly those of syphilis. The physical ex- 
amination should be careful enough to eliminate 
such chronic diseases as chronic nephritis, uraemia, 
diabetes, pernicious anaemia, Graves's disease, 
tuberculosis, syphilis, lead poisoning, and chronic 
gastritis. The condition of sleep and of the gastro- 
intestinal tract needs special attention because of 



66 METHODS OF EXAMINATION 

the frequency with which disturbances exist in 
these fields. 

The examination of the nervous system should 
be thorough and include the examination of the 
functions of the cranial nerves, the general mus- 
cular system, and the motor and sensory nerve 
functions of the trunk and extremities. A de- 
tailed method for this examination is compre- 
hended in Part I of this book (see pp. 3-52) 
and need not be reiterated here. There are, 
however, methods which are especially applica- 
ble to mental patients which will be presented 
here. 

The measurements of the cranium will give 
some indication as to the development of the 
cortex, but it is of more importance to observe 
the disproportion between the cranium and the 
rest of the body. The circumference of the 
skull taken along the line just above the exter- 
nal occipital protuberance and the glabella should 
measure in an adult between forty-eight and 
fifty-six centimeters, while the distance between 
the extreme lateral points as taken by a craniom- 
eter should be between fourteen and fifteen 
centimeters. The examination of the eye grounds 
is particularly essential as it often reveals vas- 
cular sclerosis, which might otherwise escape 



IN MENTAL DIAGNOSIS 67 

notice * Likewise, a careful examination of the 
ears sometimes discloses a sufficient cause for 
peripheral hallucinations. 

In examining the muscular system, one may 
have considerable difficulty in determining the 
condition of muscular tonicity and in eliciting 
the deep reflexes, because of lack of cooperation 
on the part of the patient and an inability to secure 
complete relaxation. The patient should be in 
a comfortable and restful attitude, such as a 
recumbent position, with his attention distracted 
by engaging him in conversation, giving him 

* In a recent communication by Clark and Tyson before 
the New York Neurological Society important observations 
were made upon eye changes in dementia praecox. According 
to these authors there is a slight grade of optic neuritis (in 
which tortuous veins and absent central cupping, paling, hazy 
disk margins going over to anaemic pale disks and partial 
atrophy), narrowing of the visual fields, corneal insensibility, 
negative Pilcz-Westphal, cilio-spinal, and psychic reflexes. 
These symptoms taken together constitute the eye syndrome 
of dementia praecox. 

Observations soon to be published by Diefendorf and Dodge 
on eye movements in dementia praecox are also of considerable 
importance and seem to give an additional positive symptom 
in dementia praecox. This symptom consists in an increasing 
inability to develop short-lived motor habits ; that is, an in- 
inability of the eye to follow the swing of the pendulum with 
perfect coordination and without certain characteristic inter- 
ruptions. 



68 METHODS OF EXAMINATION 

figures to add or something to read aloud. In 
eliciting the knee-jerks, if the patient is lying on 
his back, place the left hand beneath the knee and 
gently lift it, allowing the foot to rest on the bed. 
If you find the leg relaxed, strike the tendon at any 
time. Frequently the patient will not relax until 
you have raised the knee high enough so that it 
will support itself in that position. If the patient 
is sitting, he should recline backward in an easy 
posture, with both feet squarely on the floor and 
brought as far forward as possible without caus- 
ing the toes to leave the floor. 

The ankle clonus is best elicited now by slipping 
the right hand under the toes and sole of the foot 
and quickly jerking the foot upward for a few 
inches, so that the weight of the elevated leg and 
thigh rests on your hand. The Achilles jerk is 
determined by asking the patient to stand lean- 
ing forward and supporting his weight by placing 
his hands on the top of a table or back of a chair. 
The ankle is then lifted in the rear and allowed 
to rest on your knee, when the tendon is struck. 
The other reflexes — the jaw- jerk, the biceps, the 
triceps, the supinator and the ulnar jerks, the 
front tap and the Babinski reflex — are elicited 
in the usual way (see pp. 34-41). 

Further in the examination of muscular in- 



IN MENTAL DIAGNOSIS 69 

coordination, in addition to the usual tests (see 
pp. 31-34), one should always include the closing 
of the eyes, opening the mouth, and protruding 
the tongue upon command, and then reversing 
the order. The same test is also suitable for 
eliciting facial tremor. The muscular tests should 
also include voluntary writing and speech, reading 
aloud, as well as the enunciation of difficult words, 
such as " electricity," " Ninth Riding Massachu- 
setts Artillery Brigade," " around the rugged rock 
the ragged rascal ran." In this way there may 
be elicited scanning speech, hesitating speech, 
slurring speech, and explosive speech. 

In the sensory examination it is advisable to 
employ the simplest implements, such as a fresh 
bit of absorbent cotton, a pin, and small, similarly 
shaped bottles filled with hot and cold water, 
and for the stereognostic sense, such pocket 
articles as a coin, a pencil, etc. 

Vaso-motor, secretory, and trophic disorders 
should be recognized and recorded, particularly 
cyanosis of the extremities, dermography, glossy 
skin, canities, alopecia, onychogryphosis, naevi, 
herpes, scleroderma, and hyperidrosis; the vari- 
ous trophic disorders of the bones and joints, in- 
cluding spontaneous fractures and hematoma 
auris. 



70 METHODS OF EXAMINATION 

In the examination of the pulse there is nothing 
to be found peculiarly characteristic of any special 
form of mental disease. The blood pressure in 
fearful and depressive states is usually elevated, 
and lowered in manic states corresponding with 
the vaso-motor symptoms ordinarily accompany- 
ing these states. The fall in blood pressure ob- 
served in the end stages of paresis is in accord 
with the progressive terminal cardiac weakness. 
The examination of the blood has been thus far 
unproductive of characteristic disorders. In any 
given psychosis the blood states may vary con- 
siderably in the different stages. In the psychoses 
studied by us — dementia prsecox, manic-depress- 
ive insanity, and dementia paralytica — the only 
apparently characteristic blood states were those 
found in dementia paralytica, where there was 
a progressive anaemia, a progressive increase of 
polymorphonuclear leucocytes accompanying the 
advancing course of the disease, and the presence 
of a leucocytosis accompanying paralytic attacks. 
The chemical investigations of the urine, gastric 
contents, and of body metabolism, while still 
fruitful fields for study, do not warrant routine 
examinations except in the matter of urine and 
gastric contents to obtain indications for treat- 
ment. 



PLATE I. 



Fig. B. 



* 



Fig. A. 



Fig. B. 



'* - 




Fig. C. 



^ 



* 



Fig. D. 



IN MENTAL DIAGNOSIS 71 

A careful physical examination should include 
in doubtful cases the examination of the cerebro- 
spinal fluid for the purpose of differentiating be- 
tween functional or organic diseases. As much 
depends upon the technique, the method is briefly 
stated.* With the strictest aseptic precautions 
the needle is inserted between the fourth and 
fifth lumbar vertebrae, and three or four centi- 
meters of fluid withdrawn. Alcohol 90 per cent., 
equal to one-half the total amount of fluid with- 
drawn, is added drop by drop and well mixed. 
Centrifugalize one hour at high speed, the tube 
being closed to prevent evaporation. After 
pouring off supernatant fluid, the coagulum at 
the apex of the tube is treated successively with 
absolute alcohol, alcohol and ether, and ether, and 
mounted in celloidin. The sections are stained 
with Unna's polychrome methylene blue or Pap- 
penheim's pyronin methyl green. 

Lymphocytes (Plate 1, Fig. A) with No. 4 
ocular and -^ oil immersion normally never reach 
over 50 to 80 in 100 fields, but averaged about 
450 in 100 fields in paresis (Plate 1, Fig. C). 
Endothelial cells (Plate 1, Fig. B) are normally 
in excess of lymphocytes, but not in paresis. 
Plasma cells (Plate 1, Fig. C) can be considered 

* Cotton and Ayer, Review of Nervous and Mental Diseases, 
March, 1908. 



72 METHODS OF EXAMINATION 

pathognomonic for paresis where they average 
about 2 per cent, of the total cells present. 
At least three lumbar punctures are necessary 
for a final decision. The bacteriological ex- 
amination of the cerebro-spinal fluid, as well 
as of the blood, has thus far yielded such 
varying results in the hands of different ob- 
servers that a routine examination cannot be 
recommended for diagnostic purposes. 

The most difficult part of the examination is 
securing the mental status. In this matter 
much depends upon the acuteness of the observer, 
as the patient often enough cannot be depended 
upon for cooperation. Unfortunately, we have no 
scientific standards for determining the mental 
symptoms, but must depend upon the simplest of 
psychological tests ; namely, the asking of questions. 

For convenience and thoroughness of examina- 
tion it is most important to always have before 
one an outline of the method of examination. If 
for purposes of record or otherwise, and particu- 
larly in medico-legal cases, it is necessary to write 
down the observations, it is always best to write 
in full the question and the answer verbatim as 
given by the patient. Upon subsequent examina- 
tions the same questions should be asked, and the 
answers compared. 



IN MENTAL DIAGNOSIS 73 

This outline of examination should include 
inquiry as to (a) hallucinations and illusions, 
(b) clouding of consciousness, (c) disturbances of 
attention, (d), disturbances of memory, (e) dis- 
turbances of orientation, (/) disturbances of the 
train of thought, (g) disturbances of judgment, 
(h) disturbances of capacity for mental work, 
(i) disturbances of the emotions, (j) disturbances 
of volition and action. 

(a) Hallucinations and Illusions: — 

Illusions and hallucinations of hearing, sight, 
smell, taste, and touch. 

Hallucinations are deceptions of the senses in 
which there are no recognizable external stimuli. 
Illusions are falsifications of real percepts. 

Hallucinations and illusions of hearing and 
sight are by far the most common, and hence our 
inquiry is more especially directed to them. In 
most cases it suffices in eliciting hallucinations of 
hearing to ask directly of the patient, "Do you 
hear voices, strange or unnatural voices?" Very 
often the patient will respond at once that he 
does, and will proceed to describe them. In case 
the question is not comprehended, it is well to 
ask if he hears persons about when he cannot see 
them, or when he is alone. Some patients, not 
regarding the false perceptions as a peculiar 



74 METHODS OF EXAMINATION 

sensory experience, will promptly say that they 
do not hear strange voices. Then he should be 
asked how well he sleeps at night, if he is dis- 
turbed by people talking outside. Another fruit- 
ful source of inquiry is in reference to the presence 
of relatives, acquaintances, or associates whom you 
know to be absent. Not infrequently the patient 
will say that his employer is in the house, because 
he heard him talking only a few moments before, 
or that the father, who is really many miles away, 
just told him something. Patients sometimes 
speak in such a natural way about having received 
messages from persons whom they know to be at 
a distance, that one does not suspect its patho- 
logical character. Close questioning reveals the 
fact that they believe these messages come over 
some novel sort of a wireless telephone or by 
means of " mental telepathy." Absolute denial 
of any of these experiences is not necessarily 
convincing. One sometimes elicits hallucinations 
only when in search of the basis for delusions ex- 
pressed by the patient. Then he may inform you 
that he knows that his life is in danger because he 
overheard men in the next room plotting his 
abduction. Sometimes the hallucinations do not 
assume the form of a voice, but are considered as 
noises in the ears or ' ' indefinite whispering sounds," 



IN MENTAL DIAGNOSIS 75 

hissing noises, or sounds made by animals. But 
there are patients who deny altogether halluci- 
nations who nevertheless suffer from them. In 
such patients their presence can be established 
by observing them assume a listening attitude, 
address remarks to invisible persons, or gesticulate 
earnestly in a certain direction. On the other 
hand, one cannot infer the presence of hallucina- 
tions merely from the patients' statement that 
they hear voices; but they should be carefully 
questioned as to just where the voices emanate 
from, when and under what circumstances they 
are heard, etc., because not infrequently what 
may seem to be real hallucinations are genuine 
sensations. Patients sometimes refer to the voice 
of conscience or the voice of the heart, who in 
reality are not suffering from hallucinations at 
all. The best proof of the genuineness of halluci- 
nations is always found in the patients' reaction 
to them ; for instance, when they talk to invisible 
persons, plug their ears with cotton, or gesticulate 
intently. 

Illusions are distinguished from hallucinations 
by the determination of the presence of some 
external stimulus at the time the sensation is 
perceived — such as the ringing of a church bell, 
which is mistaken for a human voice. 



76 METHODS OF EXAMINATION 

The above methods which indicate how halluci- 
nations and illusions of hearing can be elicited 
are equally applicable in establishing the pres- 
ence of hallucinations and illusions of sight, smell, 
taste, and touch. 

(6) Clouding of Consciousness : — 

Unconsciousness is the state in which the 
transformation of physiological into psychical 
processes is completely suspended. Befogged states 
(twilight states), a partial clouding of conscious- 
ness in which neither external nor internal stimuli 
can create clear and distinct pictures. 

The determination of these states rests upon the 
person's ability to react to definite stimuli. The 
test already indicated for use in the neurological 
examinations, such as the test of the sensations 
of touch and pain by the use of the camers-hair 
brush and the pin, or the test of sight by the 
use of colors, etc., can be used. One may also em- 
ploy pictures cut from magazines, and especially 
pictures made into a medley. Questions as to 
the character of the environment and objects in 
the room also give an idea of the clearness of 
consciousness. 

(c) Disturbances of Attention: — 

Blunting of attention, in which perceptions do not 
arouse corresponding memory images, hence do 



IN MENTAL DIAGNOSIS 77 

not unite with past experience and incite a patient 
to pursue his impressions further. 

Suppression of attention occurs in stuporous 
states, when the attention cannot be aroused by 
any stimuli, even prodding with a needle. 

Blocking of the attention, in which the patient 
perceives well enough, but the perception is 
involuntarily prevented from influencing his 
thoughts. 

Retardation of the attention, in which ideas 
develop slowly, and thus prevent the perceptions 
from securing any extensive influence. 

Passivity of the attention, in which impressions 
cannot last because they are displaced by new 
impressions. 

Distractibility of attention, in which accidental 
external and internal stimuli dominate the atten- 
tion; hence attention wanders rapidly from one 
thing to another. 

Hyperprosexia, in which the attention is com- 
pletely absorbed by a single process. 

These disturbances can be well elicited by asking 
the patient to add or subtract figures successively; 
as the successive subtraction of 7 from 100 or 
the successive addition of 3, 9, or 13, observing 
the slowness or rapidity and the halts as well as 
the interruptions by other stimuli. Or the patient 



78 METHODS OF EXAMINATION 

may be asked to describe a certain well-known 
event, such as an accident, a visit, etc., noting the 
rapidity with which the successive events are nar- 
rated and how well the patient keeps to the sub- 
ject. The distractibility can be determined by 
dropping a penny on the floor or by pulling some 
striking object out of your pocket, while the 
patient is narrating this event. Some indication 
of the patient's attention can also be obtained 
while he is responding to the tests of sensibility. 

(d) Disturbances of Memory: — 

Faulty impressibility of memory, in which the 
faculty for receiving more or less permanent im- 
pressions made by new experience is impaired. 

Faulty retentiveness of memory, in which there 
is an inability to recall accurately former knowl- 
edge. 

Inaccuracy of memory, in which the relation of 
past knowledge is distorted under the influence 
of delusions or otherwise. 

Fabrications of memory, where the patient no 
longer sticks to facts, but depends altogether upon 
pure invention. 

Impressibility of memory can be best determined 
by giving the patient a series of numbers: as, 
"8746 — ring 13," and after an interval ask him 
to recall the number; or you can similarly ask 



IN MENTAL DIAGNOSIS 79 

him to recall such syllables as "ness, con, late, 
cal," or again you can show him a photograph 
and in a few moments ask him to select this 
photograph from a group of photographs. If 
patients resent such tests, one must depend upon 
such questions as: What did you have for din- 
ner yesterday ? Who were your callers this morn- 
ing ? Where did you go for your morning walk ? 
Who visited you yesterday ? etc. 

Retentiveness of memory is elicited by questions 
involving school knowledge in geography, gram- 
mar, arithmetic, history, etc. What is the defini- 
tion of a lake? Capital and boundaries of your 
states? What is a noun? What Presidents of 
the United States have been assassinated ? When 
was the Spanish- American War? etc. Further- 
more, questions as to place of residence and 
employment, year of marriage and of birth of 
children, names of teachers, etc., will test the 
retentiveness of memory. 

Inaccuracy of memory and fabrications become 
evident in the answers to questions bearing upon 
the past life of the patient and his experiences. A 
second interview is usually necessary in order to 
bring out the inaccuracies of memory, especially 
with those patients who are able to make up a 
consistent story, but who, at another sitting, give 



80 METHODS OF EXAMINATION 

an altogether different set of facts. Refusal to 
answer questions should by no means deter one 
from requesting them to write their answers, 
which mute catatonic patients will often do. 

(e) Disturbances of Orientation (disorienta- 
tion) : — 

Disorientation is a faulty comprehension of the 
environment in its temporal, spatial, and personal 
relations. 

In determining time disorientation, one should 
ask such questions as: What is the date? The 
day of the week and month ? What is the year ? 
What time of day is it ? etc. Inability to answer 
these questions correctly may be regarded as 
establishing time disorientation, providing fabri- 
cations can be eliminated. 

As to place disorientation one can ask: What 
place is this ? The city and street ? Is this your 
home or is it a church ? etc. Failure to explain 
the environment correctly means place dis- 
orientation. 

Person disorientation may be elicited by asking: 
Who are these persons about you, their names, 
and what relation do they bear to you ? etc. 

If the patient refuses to respond, evidently 
fabricates, or for any reason cannot respond, his 
disorientation may be determined by watching 



IN MENTAL DIAGNOSIS 81 

his reactions to his environment; for instance, 
noting whether or not he is able to find his way 
about, to find the lavatory, the dining room, and 
his bed, to recognize his relatives, whether or not 
he complains that the daily paper is old, or calls 
associates by unfamiliar names. 

Disorientation may arise from apathy (apathetic 
disorientation), when the patients simply lack the 
inclination to understand the meaning of what 
they see and hear ; or it may be due mostly to 
faulty memory (amnesic disorientation). Disor- 
dered apprehension may give rise to a form of 
disorientation which is called perplexity; this with 
hallucinations and delusions produces the dis- 
orientation encountered in delirious states. Still 
another type of disorientation to be differentiated 
is the delusional disorientation, which develops 
from faulty mental elaboration of impressions, 
producing delusional ideas as to time, place, and 
persons; for instance, the patient may have the 
delusional idea that the calendar date is wrong, 
but at the same time recognizing that other per- 
sons follow the usual calendar. 

(/) Disturbances of the Train of Thought: — 
Paralysis of thought, in which there is a total 
lack of associations, hence meagre responses to 
questions and very little voluntary speech. 



82 METHODS OF EXAMINATION 

Retardation of thought, in which there is a slow- 
ness and difficulty in the elaboration of impres- 
sions, producing slow response to questions. 

Compulsive ideas, which irresistibly force them- 
selves into consciousness, and are usually accom- 
panied by a disagreeable feeling of compulsion. 

Simple persistent ideas, which simply persist in 
the train of thought unaccompanied by feelings 
of compulsion. This includes perseveration, in 
which the patient uses an indicated object in the 
same way he has just previously used another. 

Circumstantiality, in which the train of thought 
is interrupted and delayed by the introduction of 
many non-essential accessory ideas and renders the 
relation of an incident tedious and long drawn out. 

Flight of ideas, in which there is a rapid change 
of goal ideas, while the successive links of the 
chain of thought still remain fairly well united. 

Desultoriness, in which there is a complete loss 
of goal ideas, so that ideas follow each other 
abruptly and disconnectedly. 

If the patient is communicative, one has already 
had a chance in following the answers to questions 
bearing on the physical examination to deter- 
mine the presence of disturbances of the train 
of thought. Questions relative to the memory of 
the patient should give one an idea of the wealth 



IN MENTAL DIAGNOSIS 83 

or the impoverishment of his store of ideas. If 
the patient answers in monosyllables, as "Yes," 
"No," or "I don't know," or simply gives single 
facts, without entering into a description of inci- 
dents asked about, paralysis of thought may be 
suspected. This is more probable if after more 
than one seance you fail to find anything that 
interests him and about which he can talk, in- 
cluding his home, his employment, his pleasures, 
or church or social relations. Paralysis of thought 
must not be mistaken for retardation, in which the 
patients also have little to say. Persistent inquiry 
and prodding usually shows that the patient suffer- 
ing from retardation of thought has plenty of ideas, 
only it is difficult to drag them out. Further- 
more, his speech is not only meagre, but also slow 
and uttered in low tones. Compulsive ideas are 
usually volunteered by the patient. If not, a 
simple question as to whether he is troubled by 
disagreeable ideas, which are constantly recurring 
and accompanied by uncomfortable feelings, should 
suffice in eliciting them. 

Simple persistent ideas are usually self-evident 
if the patient is communicative ; for instance, the 
catatonic patient may repeat for hours such per- 
sistent ideas as, "I want my wife, I want my 
wife," etc. Patients may suffer from persistent 



84 METHODS OF EXAMINATION 

ideas without expressing them, then one must ask 
directly if simple ideas are persistently recurring 
in their minds. 

Perseveration may be discovered in voluntary 
speech, but is best elicited by asking the patient 
to name different objects placed before him, such 
as knife, watch, pencil, etc. 

Circumstantiality, flight of ideas, and desultori- 
ness very often occur in patients who are voluble, 
and hence there is little difficulty in determining 
their presence. If, however, the patient is not 
voluble, one is often able to discover the defects 
by asking the patient to relate connectedly the 
incidents of some recent personal experience, such 
as a detailed account of his daily routine or of 
his journey to the hospital, etc. Prodding the 
patient during the narrative by interjecting, 
"Yes, yes/' or "Is that so?" often serves to keep 
up the stream of thought. A very important 
method in determining the train of thought is to 
examine the voluntary writings of the patients, 
their letters to friends and relatives, their written 
requests, etc. 

There are more accurate tests for determining 
the association of ideas, some of which are of 
clinical value. Give the patient a noun, such as 
"man," and ask him to speak aloud the ideas that 



IN MENTAL DIAGNOSIS 85 

first arise in his mind. Or you may request the 
patient himself to jot down in order all of the ideas 
arising in his mind after the initial word has been 
given. This test enables one to determine the 
relationship between the inner and external asso- 
ciations, — the prevalence of fixed associations, 
sound associations, also the tenacious holding of 
single ideas, the tendency to sudden halting — 
and finally the wealth of the store of ideas. 

Many patients will not lend themselves to such 
tests, and then one must depend upon their 
voluntary productions and answers to questions. 
Furthermore, there are patients who refuse to 
answer questions, but are nevertheless voluble. 
In such cases, it is necessary to follow carefully 
the content of thought, employing if necessary a 
stenographer, because such voluntary speech may 
furnish the necessary clew as to the form of men- 
tal disease from which they are suffering. 

In describing the disturbances of the train of 
thought it is well to employ the term " confusion," 
a term to be used only in connection with the dis- 
order of thought; such as " confusion with flight 
of ideas " or " desultory confusion . ' ' 

(g) Disturbances of Judgment: — 

Delusions — morbidly falsified beliefs which can- 
not be corrected by argument or experience. 



86 METHODS OF EXAMINATION 

Systematized and unsystematized delusions. Sys- 
tematized delusions centre about some one or 
more definite objects, i.e. become a part of a 
system. 

Delusions of self-aggrandizement include ex- 
pansive delusions, delusions of grandeur, and 
delusions of health. 

Expansive delusions, in which the patient be- 
lieves himself possessed of wealth, of great power, 
of influence, or of unusual qualifications. 

Delusions of grandeur are expansive delusions of 
an extreme degree. 

Delusions of self-depreciation include delusions 
of persecution, of self-accusation, of misfortune, 
of jealousy, also nihilistic and somatic delusions 
and many others. 

Delusions of persecution, in which the patient 
believes that he is subjected to various forms of 
persecution. 

Delusions of self-accusation, in which the patient 
believes that he has committed sin and is unworthy. 

Delusions of misfortune, in which the patient 
believes that misfortune has befallen him. 

Delusions of jealousy, in which the patient dis- 
trusts the fidelity of relatives and friends. 

Nihilistic delusions, in which the patient believes 
that things are non-existent. 



IN MENTAL DIAGNOSIS 87 

Somatic delusions, in which the patient's absurd 
beliefs refer in some way to his body or its organs. 

If the delusions held by the patients are at all 
prominent, one would undoubtedly have encoun- 
tered some of them by the time this stage of the 
examination had been reached, or there would have 
been at least some hint, which would serve as a 
basis for further inquiry. In eliciting delusions, 
direct questions are less pernicious than in search- 
ing for some of the other symptoms. Hence, one 
may ask directly : Are you persecuted in any way ? 
Have you enemies ? Do you possess much wealth ? 
Are you troubled? Are you grieving over some- 
thing you have done ? Is there anything the mat- 
ter with your body ? your heart ? lungs ? stomach ? 
etc. Are you disturbed by peculiar influences ? etc. 

In case such questions fail to elicit delusions, 
and the patients show reserve and tend to answer 
briefly and abruptly, or refuse altogether to speak 
of personal matters, one must be tactful in uncov- 
ering delusional ideas. Sometimes if the patients 
are disturbed because of the restraint of liberty or 
because they must submit to nursing and medical 
attention, one can disclose delusions by simply 
asking why they have been deprived of their lib- 
erty, or are under the care of a physician. More 
often it is necessary to introduce some subject of 



88 METHODS OF EXAMINATION 

personal interest, such as their employment, their 
travels, favorite literature or recreation. Follow- 
ing up closely the personal element in the conversa- 
tion, some hint as to delusional ideas is apt to be 
inadvertently dropped. Again one may ask such 
questions as : What is your idea of trusts ? Have 
you ever been a member of a trade union, and 
has it benefited you ? Where have you travelled, 
and what countries did you most enjoy? A full 
discussion of matters of mutual interest, particu- 
larly matters that concern the patient's livelihood, 
very often disclose delusions that cannot be other- 
wise elicited. Among women, domestic cares, 
church and social relations, and especially neighbor- 
hood differences are fruitful sources for discussion. 

Somatic delusions may be elicited by such ques- 
tions as : Are you in good health ? Is there any- 
thing the matter with your heart, lungs, stomach, 
limbs, sexual organs, or head ? Do you sleep well ? 
or, Do you enjoy your food? 

After one has elicited the various delusions, evi- 
dence as to systematization of the delusions can 
usually be established by asking : What is the 
purpose of all this, and what is to be the outcome ? 
Do these various experiences have anything to 
do with each other? 

In some cases even exhaustive questioning and 



IN MENTAL DIAGNOSIS 89 

close observation for days and weeks may fail to 
disclose delusions of any type. In such instances 
it is necessary to resort to a patient scrutiny of 
all the individual's acts and writings. If delusions 
are really present, it is usually only a matter of 
time before the conversation or conduct will reveal 
them. Sometimes the disclosure comes through 
such simple acts as the fact that the patient is 
observed to wear several thicknesses of paper in his 
shoes, or to make use of an unusual color of ink 
in writing, or wears a certain style of cap. Inquiry 
as to the reason for such conduct may open up 
a whole host of delusions. 

Impaired judgment in matters other than the 
delusion can usually be determined during the 
discussion of such subjects as are suggested in the 
preceding paragraphs, and by such questions as : 
How do you explain your confinement and the 
restriction of your liberty? Is it just? Are you 
able to support your family ? Do others aid you 
as much as they should in providing for the 
home? To what trade unions, social orders, or 
business associations do you belong, and how do 
you benefit by them? etc. 

(h) Disturbances of Capacity for Mental Work: — 

Increased susceptibility to fatigue. 

Impaired recovery by relaxation and sleep. 



90 METHODS OF EXAMINATION 

Faulty application due to distractibility. 

These disturbances can be determined both by 
inquiry and by observation. The patient can be 
tested by such tasks as writing letters or to dicta- 
tion, or by the performance of some simple duty. 
The tests suggested for determining the association 
of ideas will also give one a hint as to the capacity 
for mental application. As for the recovery from 
fatigue by relaxation and sleep, one must depend 
upon the patient's own statement and observation 
of his reaction to sleep and relaxation. Distrac- 
tibility is easily determined by watching him as he 
passes abruptly from one unfinished undertaking 
to another. 

(i) Disturbances of the Emotions : — 

Emotional deterioration (emotional indifference or 
apathy), in which the patient fails to show a normal 
amount of interest. 

Increased emotional irritability (changeable 
mood), in which the feelings of the patient are 
intensified and hence give rise to rapid changes 
of mood. 

Morbid emotions, in which the patient presents 
either morbid fear, morbid dejection (melancholy), 
or morbid pleasure (wanton happiness, feeling of 
well-being, ecstasy). 

Disturbances of the feeling of nausea, hunger, 



IN MENTAL DIAGNOSIS 91 

'pain, shame, and of sexual feelings, in which the 
patient presents either an increase, a diminu- 
tion, or a perversion of some of these feelings. 
In determining the disturbances of the feelings,* 

* The recent work of Jung and Peterson, published in 
Brain, 1907, suggests a new and probably reliable method of 
determining disturbances of the feelings. They make use of 
a mirror galvanometer of Duprez-d'Arsonval made by Car- 
pentier of Paris (Model A, suspension thread 0.08 mm., 
duration of simple oscillation 1.69 seconds, resistance 6.2 
ohms). The reflected light may be thrown either upon the 
screen by means of an arc light or for more accurate work upon 
a millimeter scale. The test person is put in the circuit with 
the galvanometer and one dry cell and a shunt is also employed 
to regulate the amount of current. The electrodes are nickel- 
plated copper upon which the hands or feet may rest. When 
the test person is placed in the circuit, and every possible 
stimulus avoided, one obtains a rest curve characterized first 
by a considerable deflection and then a slow recession of the 
curve to almost nothing. When any stimulus is applied, 
sensory or psychic, such as a shrill whistle or a remark 
calculated to arouse fear, anger, or pleasure, there appears, 
after a latent period of two to five seconds, a rise in the curve 
and then a gradual fall to the previous level. An emotional 
deterioration is shown by the absence of or very slight devia- 
tion of the curve. The tests may include association tests 
with words. Lifting or moving the fingers or hands causes 
the light to recede. Strong pressure may cause the light to 
advance, but such muscular movements are readily detected 
and do not complicate or interfere with the curves due to the 
emotions. Also, deep inspiration or expiration or coughing 
will cause a deflection, but all these influences are readily 
distinguishable by practice. 



92 METHODS OF EXAMINATION 

one is forced to depend more upon observation of 
the patients' reaction to their environment and 
their conduct than upon inquiry as to how they 
feel, because the replies to such questions are apt 
to be inaccurate and falsified. For instance, most 
patients, if asked if they love their parents, would 
reply, "Yes," in spite of the fact that they never 
give evidence of feeling when visited by parents 
and may not even appear to recognize them. Ob- 
servation of the patients 7 reactions toward their 
relatives, their work, and in their social environ- 
ment is far more reliable than what the patients 
may say as to their feelings. Yet in determining 
apathy, one should also question the patients as 
to their interest in matters that are known to have 
formerly interested them. Unusual and excessive 
emotional reaction to the environment or rapid 
change of mood for trifling reasons may ordinarily 
be regarded as evidence of increased emotional 
irritability. In making inquiry of the relatives 
and friends as to the patient's reaction, one should 
ask such questions as: Has there been a change of 
disposition, and how has it been shown? Has 
he become quiet, solitary, timid, despondent, irri- 
table, suspicious, egotistical? Have his feelings 
changed toward his family or his friends ? Has he 
lost interest in his employment or profession, in 



IN MENTAL DIAGNOSIS 93 

the church, social or fraternal orders ? Has he be- 
come negligent of his family or his business obliga- 
tions? Has he become insensible to the feelings 
or interests of others, or does his conduct show 
unnatural fear, sadness, or exaltation ? 

The morbid emotions, i.e. dejection, fear, ela- 
tion, feeling of well-being and ecstasy, usually 
become quite evident during a prolonged exami- 
nation and do not necessitate special inquiry, be- 
yond asking the patients, How do you feel ? 

As to the general feelings, the absence of the feel- 
ing of pain, of nausea, of shame, etc., again you 
must usually rely upon the observation of the pa- 
tient and his general conduct, except in the mat- 
ter of the sexual life, which the patient may be 
able to control while under observation. 

There are no very accurate means of measuring 
the emotions except the psycho-physical galva- 
nometer test of Jung and Peterson (see p. 91). 
Feelings of displeasure, of pain, fear, and anger 
can be created experimentally in various ways 
and by hypnosis. Furthermore, the writing scale 
and the ergograph, which are used to measure the 
finer expressions of the will, are serviceable in 
measuring the outward expressions of emotional 
excitement. 

(j) Disturbances of Volition and Action: — 



94 METHODS OF EXAMINATION 

Paralysis of the will, in which the patient pre- 
sents a morbid lack of energy (anergy). 

Motor excitement (pressure of activity), in which 
there is a " marked disproportion between the 
intensity of the excitation and the importance of 
the motive." 

Psychomotor retardation (stupor) , in which every 
movement requires a special exertion of the will, 
rendering all acts slow in their execution. 

Blocking of the will (rigid muscular tension), in 
which acts are properly and quickly begun but 
are almost immediately overwhelmed by opposing 
impulses, so that the patient maintains uncom- 
fortable positions for hours, shows muscular ten- 
sion, and does not shrink when threatened and 
pricked with a pin. 

Hypersuggestibility of the will (catalepsy, flexi- 
bilitas cerea, echopraxia, echolalia), in which the 
control of the will is lacking so that patients 
become a prey to every accidental influence: the 
limbs remain in whatever position they are 
placed (catalepsy), or can be moulded like wax 
(flexibilitas cerea), or acts seen are imitated (echo- 
praxia), or speech of others is laboriously repeated 
(echolalia). 

Distractibility of the will, in which there is a 
morbidly easy translation of ideas into action, so 



IN MENTAL DIAGNOSIS 95 

that acts are only half completed before new ones 
are begun. 

Interference, in which the carrying out of an im- 
pulse is interfered with by the interpolation of in- 
congruous impulses, so that acts of the patient are 
inappropriate. 

Stereotypy, in which acts once begun are repeated 
indefinitely. 

Mannerisms, in which acts are peculiarly modi- 
fied, so that the patient assumes a peculiar manner 
of walking, talking, or moving, etc. 

Negativism, in which there is an impulsive re- 
sistance to every outer influence of the will, so 
that the patient does just the opposite of that 
which one would expect normally, i.e. refuses to 
answer questions (mutism), closes his eyes tightly 
when asked to open them, etc. 

The determination of these disturbances of voli- 
tion depends chiefly upon the observation of the 
conduct. One cannot rely altogether upon the 
spontaneous activity, but should also observe 
conduct in reaction to command and suggestion. 
Thus, anergy can be determined not only by watch- 
ing the patient's voluntary movements, but also 
his reaction to a request to perform some simple 
duty or his response to the dinner call. Also, 
pressure of activity and retardation can usually 



96 METHODS OF EXAMINATION 

be observed without difficulty. On the one hand, 
the patient can hardly restrain himself during the 
examination, but must be talking or " on the move " 
constantly; while the retarded patient has to be 
prodded in order to get him to move or to speak, 
and such simple requests as to write the name 
and address are done very slowly and after much 
apparent deliberation. In eliciting retardation, 
it is also well to request the patient to count from 
one to thirty as rapidly as he can, or to subtract 
seven from one hundred successively. 

Blocking of the will, interference, and mannerisms 
are usually apparent in the spontaneous activity 
of the patient, but it may be necessary to request 
the patient to shake hands with you, to walk about 
the room, or to pick up a book and open it to a cer- 
tain page, or other such acts in order to bring out 
these peculiar defects. The patient with blocking 
of the will will start to shake hands or to pick up 
something and then suddenly cease, and maintain 
a rigid attitude, while the patient with interference 
will add all sorts of frills to his movements before 
the act is accomplished, such as to turn around or 
twist his hand into an awkward position. The 
manneristic patient will grasp your hand pecul- 
iarly, stand on one foot, or perform the act in 
some peculiar manner. A favorite method of de- 



IN MENTAL DIAGNOSIS 97 

termining the presence of muscular tension is to 
approach the patient with a needle and threaten 
to pierce his eyelid or ear or to prick his ringer. 
At such time he may start to withdraw, but 
almost immediately submits stolidly to what- 
ever you do. 

As regards catalepsy and flexibilitas cerea, one is 
quite certain to elicit these defects during the 
physical examination, when, for instance, a limb 
raised to a certain position is found to remain 
there indefinitely or where one encounters a uni- 
form wax-like resistance to all passive movements. 
In case these disorders are not apparent, one has 
simply to grasp some portion of the body and 
place it in an awkward or uncomfortable position. 

Distractibility of the will is very apt to be accom- 
panied by pressure of activity where there is plenty 
of voluntary movement, hence in determining dis- 
tractibility it is necessary only to watch the patient 
and observe whether or not his acts are completed 
before new ones are undertaken. Or you may re- 
quest the patient to perform certain acts, as to 
write his name and address or to fetch a certain 
book from the table. 

The same holds true of stereotypy, which is usu- 
ally so self-evident in the spontaneous activity of 
the patient as not to need special tests. If it hap- 



98 METHODS OF EXAMINATION 

pens not to be apparent, then request the patient 
to perform certain acts similar to those noted above. 
In eliciting negativism, one has to depend mostly 
upon attempts at passive movements, but also 
upon the absence of a natural response to requests. 
The tests employed for detecting catalepsy and 
flexibilitas cerea also demonstrate negativism. 
The arm of the patient when grasped, even very 
lightly, resists movement in any direction. If one 
attempts to lift the arm, it is forced further down- 
ward, while an attempt to force it downward is 
met by an effort to raise it. One's hand pressed 
against the forehead meets active resistance, so 
that if suddenly removed the head bobs forward, 
and if the hand is placed against the back of the 
head, a similar resistance is met. 

Inquiry as to conduct of the patient as observed 
by others, particularly as regards these disorders 
of volition, is quite as important as the personal 
examination, as the intensity of these defects 
varies and hence may not be as evident at the time 
of the examination as at others. Indeed, patients 
are less apt to exhibit them when they believe 
themselves observed. Such inquiry from nurses 
and parents will prevent your overlooking many 
important conditions, particularly such negativ- 
istic tendencies as eating only the food of others, 






IN MENTAL DIAGNOSIS 99 

getting into others' beds, etc., also the assuming 
of constrained and awkward attitudes. 

In the finer analysis of disturbances of volition, 
particularly psychomotor excitement, retardation, 
and tension, Kraepelin suggests the writing scale, 
by which one can determine the path of the writ- 
ing, the rapidity, and the pressure. Also the 
ergograph, invented by Mosso, can be employed to 
measure the strength of the movement, the effect 
of retardation, fatigue, and muscular tension, as 
well as the rapidity with which the contraction and 
relaxation of the muscles follow under the influ- 
ence of the impulses of the will. Both of these 
instruments, however, have their drawbacks, which 
render their routine application unsatisfactory. 
The more severe disturbances in the release of the 
volitional impulses can be measured by the use of 
the watch, such as in counting as rapidly as pos- 
sible from one to thirty, rapidly repeating the 
alphabet, or in simply raising the arm. 

The importance of more than one examination of 
the patient cannot be overestimated. The char- 
acter of the examination, in which there is so little 
that is objective and so much that depends upon 
the response of the patient, renders the liability 
of error much greater than in the ordinary neuro- 
logical examination. One should be able to make 



100 METHODS OF EXAMINATION 

at least three mental statuses before being called 
upon for an opinion. This gives an opportunity 
to check up the accuracy of the patient's memory 
of his personal history, to compare the spontaneous 
speech productions, to elicit full details as to delu- 
sions, and to determine if the delusions are change- 
able, if they continue to involve the environment, 
and are constantly being enlarged, or systematized. 
Furthermore, one's first introduction to a patient 
does not always conduce to such perfect ease, free- 
dom, and confidence as to make possible a full and 
satisfactory status. Finally there are some patients 
who are so adroitly secretive that several exami- 
nations are necessary before one uncovers the real 
mental status. 

Records of the subsequent examinations should 
be as full and complete as of the first. 



CHAPTER II 

The common forms of insanity encountered 
most often by the practitioner are : (1) dementia 
praecox, which comprises three groups of cases: 
(a) the hebephrenic, (6) catatonic, and (c) paranoid; 
(2) dementia paralytica (paresis); (3) melancho- 
lia; (4) manic-depressive insanity, comprising the 
(a) manic and (6) depressive phases; (5) paranoia; 
(6) acute alcoholic hallucinosis and (7) acute conf u- 
sional insanity (amentia).* In this chapter speci- 
men cases of these several forms of mental disease 
are so detailed as to give an idea of the important 
mental symptoms in each and the method of mak- 
ing and recording the mental status. 

1. Dementia Pjlecox 

(a) Hebephrenic Form 

Family History. — The paternal grandmother 
was insane and the maternal grandmother, as well 
as two maternal aunts suffered from Huntington's 

* For a full description of these and other forms of in- 
sanity, see Clinical Psychiatry, Macmillan, 1907. 

101 



102 METHODS OF EXAMINATION 

chorea. The mother has always been a frail woman 
of nervous temperament. 

Personal History. — From childhood patient has 
always been "delicate and extremely nervous." The 
establishment of menstruation was difficult and for 
many months the " periods were accompanied by 
fainting spells." She was of a sociable disposi- 
tion, but chose companions much older than her- 
self, and in other ways seemed mature for her years. 

Psychosis. — Onset gradual. At the expiration 
of freshman year at college she was found to be 
unusually nervous, irritable, and " frequently lost 
control of herself." She quite recovered her men- 
tal health by fall and was able to reenter college, 
but by the end of the second month she began to 
complain of difficulty in trying to study and "of 
blank feelings" in her head. Her work suffered 
materially ; there were days when she would make 
brilliant recitations and others when she would be 
stupidly dull. 

Physically, she was suffering greatly from in- 
somnia and was steadily losing in weight. Very 
soon after removal from college she underwent a 
complete change of disposition. Naturally of a 
mild, amiable, and conscientious temperament, 
she now became self-assertive, egotistical, deceit- 
ful, vulgar, and quarrelsome. Aural hallucinations 



IN MENTAL DIAGNOSIS 103 

also developed almost immediately, and she claimed 
that strange voices directed her thoughts and 
told her what to do. She expressed indefinite 
expansive delusions, such as that she would give 
birth to the second Christ, and that she was a 
wolf, and in accord with such ideas would snarl 
and growl like a wolf, at the same time attacking 
her mother. She did not lose her orientation and 
was conscious of where she was and those about 
her. Her memory, however, seemed to fail, as she 
was unable to keep track of passing events. She 
was extremely irritable and lost all interest in her 
personal appearance and college work. At times 
she would be momentarily happy and amiable, but 
this would quickly give way to surliness and irri- 
tability. Her conduct was mostly in accord with 
her many hallucinations and delusions and her 
varying moods. She was careless of her personal 
appearance and untidy about her person. 

During the succeeding nine months the patient 
was kept at home and with difficulty cared for by 
her mother. She continued to express hallucina- 
tions of hearing and many incoherent delusions 
and was less and less able to care for herself. She 
had continued to lose in weight and the menses 
had not appeared for six months. Her appetite, 
also, was poor. 



104 METHODS OF EXAMINATION 

At this time she was first examined, the status 
prsesens showing: — 

Perception. — Many auditory hallucinations are 
expressed : " God talks to me and tells me what 
to do." " These people here say vile and vulgar 
things about me." " Spirits also talk to me," etc. 
In reaction to these hallucinations patient is often 
seen in conversation with invisible persons. Other 
hallucinations and also illusions are not elicited. 

Consciousness is unclouded. 

Apprehension is quite clear and external impres- 
sions are correctly apprehended. 

Attention is faulty. During conversation there 
is evident blunting of attention. When ques- 
tioned she usually answers in monosyllables. Even 
questions about college life fail to hold the atten- 
tion. When requested to subtract seven from 
one hundred successively, she starts rapidly but 
ceases altogether upon reaching seventy-nine, 
begins to look about the room and says nothing 
further. Absorbing interest in things has disap- 
peared and she says but little. 

Memory. — The impressibility of memory is 
considerably impaired, as patient cannot give cor- 
rectly the date of leaving college, the names of her 
college professors, the duration of her hospital 
residence, who accompanied her to the hospital, 



IN MENTAL DIAGNOSIS 105 

etc. Shown one of a series of photographs and 
later asked to identify it among others, utterly 
fails. The retentiveness of memory is also some- 
what impaired, as shown in her inability sometimes 
to recall school knowledge, such as adding and sub- 
tracting. In this matter there is some variation 
because at times she is overheard conjugating to 
herself German verbs, which she cannot conjugate 
when quizzed. 

Orientation is impaired. There is partial time 
disorientation : the day of the week is Thursday 
(Monday), the day of the month is November thir- 
tieth (November twenty-third), while the year is 
given correctly. As to place, she knows the city 
and at times gives correctly the name of the insti- 
tution, while at others she calls it a mansion ; and 
as to persons, she refers to those about her as girls, 
but cannot say why they are here. 

Train of Thought. — There is evident desultori- 
ness of thought, as may be seen from the following 
productions: What is your name? "You people 
have the lock and key. Must be that I am at 
home. Are you still writing (sees physician writ- 
ing) or dictating ? Oh, dear ! that spoils the sea- 
sons. Certainly I am L B ." At times, 

during the interview, questions may be answered 
quickly, coherently, and to the point; but the 



106 METHODS OF EXAMINATION 

above is a fair sample of her train of thought. 
There is also evident paresis of thought, as pro- 
longed questioning discloses only a limited store 
of ideas. 

Judgment. — She expresses a few illy defined 
expansive delusions, such as that she is pretty, 
accomplished, and witty, and that she may some- 
time give birth to a second Christ, etc. She has 
no insight into her condition. 

Capacity for mental work of any kind has en- 
tirely disappeared. She may occasionally pick up 
a book or paper, only to look at a picture and again 
lay it down. College text-books placed before her 
never create any interest. 

Emotionally j the patient exhibits most promi- 
nently emotional deterioration, seen in her general 
apathy and indifference not only to occurrences in 
her environment but as well to the visits of her 
mother. She never speaks of college work or of 
her future. At times she gives some evidence of 
transitory elation when she laughs and sings or 
dances about for a few moments at a time. Irri- 
tability is also exhibited by her sudden surliness 
and refusal to speak or obey. 

Volitionally, there is some evident paralysis 
of will, shown by her lack of voluntary activity. 
She tends to remain alone and unoccupied most 




Fig. 26. Hebephrenic Form of De- 
mentia Praecox, showing Silliness 
and Untidiness. 



IN MENTAL DIAGNOSIS 107 

of the time, usually sitting in one place, looking 
stupidly at the floor, or gazing about indifferently. 

Conduct — In addition to facts already stated, 
patient has almost no care of her person. Silly 
and purposeless laughter is very prominent. 
Suddenly and without evident cause she bursts 
out into loud and unrestrained laughter, and just 
as quickly ceases. Often, also, she is seen smiling 
to herself even during conversation and is never 
able to assign a reason for it. 

Three other mental statuses revealed nothing 
beyond the observation of an increased tendency 
to mannerisms, such as standing and walking on 
her toes. 

Hence the diagnosis of dementia precox, 
hebephrenic form, characterized by gradual de- 
velopment of increasing dementia, observed in the 
paralysis of thought, emotional deterioration, and 
loss of voluntary activity, aural hallucinations, 
and indefinite expansive delusions. 

(b) Catatonic Form 

Family History. — " Mother once insane and 
recovered." 

Personal History. — Patient has always been a 
" nervous child," especially so since the death of 



108 METHODS OF EXAMINATION 

her father at twelve years. Menstruation estab- 
lished early; menses irregular and prolonged. 

Psychosis. — Onset rather sudden at fifteen 
years of age. Immediately following the funeral 
of a beloved aunt she became "hysterical," 
"laughed and cried beyond control" for several 
hours, and then became profoundly despondent. 
She remained alone and cried much, claimed that 
she had lost all friends, and wanted to die. She 
asked frequently to visit the priest, because she felt 
that she had committed sin, but knew not what. 
Auditory hallucinations were occasionally noticed. 
Among other things she heard her father's voice 
announcing that she would die. Consciousness 
remained clear, attention good, memory unim- 
paired, orientation good, and train of thought un- 
disturbed. Although greatly depressed, there was 
no evident retardation, as she spoke both rapidly 
and clearly. 

Physically, she lost in weight rapidly, slept very 
poorly, took sparingly of food, and was consti- 
pated. She did not suffer from any attacks. 

This despondency lasted two weeks, when she 
suddenly became greatly excited. The emotional 
depression was replaced by elation, and the quiet- 
ness and seclusiveness by pressure of activity and 
boisterous, noisy behavior. 



IN MENTAL DIAGNOSIS 109 

Hallucinations of hearing continued, but were 
altogether of a religious and pleasing nature : God 
commended her and told her that she was blessed, 
friends at a distance sent pleasing messages, etc. 

Consciousness remains clear and apprehension of 
external impressions unimpaired. 

Attention is somewhat distractible, and her 
voluble speech consists mostly of comments upon 
what she sees and hears. 

Memory. — Impressibility of memory is im- 
paired, as patient cannot recall accurately events 
since the onset of her illness, or what is transpiring 
about her, and is quite unable to repeat groups of 
numbers or senseless syllables which are given to 
her to remember. On the other hand, remote 
events are accurately recalled, when her attention 
can be held long enough to elicit them. 

Orientation is good in all respects. 

Train of Thought — The patient is very voluble. 
The content of her thought shows some incoherence 
in the form of simple persistent ideas and verbi- 
geration, i.e. the same meaningless words and sen- 
tences were repeated over and over, such as "let 
him come," " let him come," and " Hello," " Hello." 
Again at times she also shows echolalia, when she 
will repeat over and over what she hears; for in- 
stance, when addressed, "Come now, get up for 



110 METHODS OF EXAMINATION 

breakfast/' she will repeat, "Come now, get up for 
breakfast/' etc. 

Judgment — She expresses a few changeable 
expansive delusions of a religious nature, such as : 
"I am the Virgin Mary." "I am so powerful, I 
can make you do what I want," etc. She has no 
insight into her condition and insists that she is 
perfectly well and capable of work. 

Capacity for mental work is completely destroyed 
by her pressure of activity, hypersuggestibility, 
and distractibility. 

Emotionally , she presents constant morbid ela- 
tion and happiness, and is always smiling and 
laughing, and often bursts out into unrestrained 
laughter. 

Volitionally, she presents a pressure of activity 
which is characterized by identical movements fre- 
quently repeated, usually taking place within a 
narrow range ; for instance, she will force her feet 
up and down in bed for hours at a time, or tap with 
her fingers on the same spot on the wall or bed- 
stead, or pull vigorously at the lobe of one ear. 
The movements are usually quite senseless. 

In addition, hypersuggestibility of the will is 
present, as shown by her echolalia and echopraxia, 
i.e. she frequently imitates by word and action 
what she hears and sees, repeats what the physician 
says and imitates his movements. 



IN MENTAL DIAGNOSIS 111 

Conduct — She is untidy and filthy. She 
smears her food and excrement, disrobes and ex- 
poses her person. Occasionally, she attacks those 
about her impulsively. 

Physically, the nutrition is faulty and weight has 
continued to fall. There is very little sleep, and 
constipation continues. There have been no 
attacks. In addition to the exaggerated tendon 
reflexes, dermatographia is present. 

After ten days of this catatonic excitement the 
patient one morning was found in a condition of 
catatonic stupor. She lay outstretched in bed. 
She would not respond to questions or com- 
mands, and refused nourishment. The mental 
status taken at that time was as follows: — 

Perception could not be determined because of 
patient's mutism. Her conduct, however, did not 
indicate the presence of hallucinations or illusions. 

Consciousness and apprehension also could not 
be determined. 

Attention. — Patient's attention could not be 
attracted. Her gaze appeared fixed on something 
in the distance and could not be diverted by any 
sort of stimulus. 

Memory likewise could not be determined be- 
cause of patient's mutism. 

Orientation and judgment, also, could not be 
elicited. 



112 METHODS OF EXAMINATION 

The capacity for mental work was completely 
destroyed by the stuporous state. 

Emotionally, although the patient said nothing, 
her countenance at times seemed to indicate hap- 
piness and ecstasy, while at others it was wholly 
impassive. 

Volitionally, she exhibited negativism (see 
Fig. 27), as shown by her refusal to speak (mut- 
ism) and eat. She resisted every attention; when 
food was placed at her lips, she pressed them 
tightly together; when an effort was made to 
open her mouth, the teeth were set; and when 
one attempted to move her in bed, the entire 
body stiffened out rigidly ; likewise, when the head 
was raised, the muscles at the back of the neck 
tended to force the head backward into the pillow. 
At other times, hypersuggestibility was present 
in connection with negativism. Though she 
was still mute and refused food, the limbs could 
be placed in any desired position, where they 
would remain for some time (catalepsy). Less 
frequently the limbs presented a waxlike resist- 
ance and could be moulded into different posi- 
tions (flexibilitas cerea). (See Fig. 28.) 

In conduct, in addition to what is already indi- 
cated, she was wholly incapable of caring for her- 
self. She lay quietly in bed, never making a 




Fig. 27. Catatonic Stupor with Negativism. 




Fig. 28. Catatonic Stupor with Flexibilitas Cerea. 



IN MENTAL DIAGNOSIS 113 

voluntary movement except as shown by her nega- 
tivism in reaction to certain stimuli. At times 
even the act of micturition was resisted until the 
bladder became greatly distended, necessitating 
catheterization. For the same reason it was at 
times necessary to give enemata. 

Physically, no further change had occurred. 

Although it was impossible at that time to judge 
the condition of perception, consciousness, appre- 
hension, memory, attention, and judgment, it was 
elicited from the patient after the stupor cleared 
that she had memory for many of the events during 
the stupor, that she was in large measure conscious, 
apprehended external impressions, and was capable 
of attention. Delusions during this period were 
denied. 

Diagnosis. — Dementia precox, catatonic form, 
characterized by preliminary despondency with 
occasional auditory hallucinations and depressive 
delusions, sudden development of excitement with 
auditory hallucinations, clear consciousness, dis- 
tractibility of attention, simple persistent ideas, 
verbigeration, echolalia, expansive delusions, emo- 
tional elation, pressure of activity and echopraxia, 
followed suddenly by a condition of stupor with 
negativism, mutism, catalepsy, and flexibilitas 
cerea. 



114 METHODS OF EXAMINATION 

(c) Paranoid Form 

Family History. — One sister is a " trifle queer," 
otherwise negative. 

Personal History. — Patient was always unusu- 
ally religious and also showed considerable sexual 
excitability, having been for years subject to fre- 
quent nocturnal emissions. Friends regarded hirn 
as a hypochondriac. 

Psychosis. — Onset was gradual and without 
evident cause at thirty-six years of age, when pa- 
tient became mildly despondent, left his employ- 
ment, and began to complain of hallucinations of 
hearing: "They keep calling me Jack/ 7 etc., also 
delusions of persecution, such as, "They tried to 
drive me out of the boarding house and out of 
the shop." Then sexual delusions developed: he 
thought that remarks of his associates referred to 
his sexual organs, and that fellow-boarders who 
roomed over him carried on illicit relations just 
to annoy him. Thus he was driven about from 
place to place for three months, but ultimately 
returned home because "the persecutions were the 
same wherever I was." By the fourth month he 
developed many somatic delusions to the effect that 
the immoral conduct of others affected his kid- 
neys, that his "wind and heart strings had been 



IN MENTAL DIAGNOSIS 115 

pulled at so that he parted in two and his bladder, 
stomach, and bowels came out," etc. He became 
agitated and fearful of personal injury and took so 
sparingly of food that he lost in weight. This state 
of agitation lasted three weeks, when he quite sud- 
denly became moderately elated and expressed 
many expansive religious delusions; namely, that 
he had died and had been made over into a new 
man, and had become the husband of the Virgin 
Mary ; that his actions were now directed by God, 
whose voice with that of the Virgin Mary he heard 
daily. From this time until the time of the exami- 
nation in the ninth month, the patient is said to 
have suffered from constant hallucinations of 
hearing, which consisted mostly of commands from 
God and the Virgin Mary. From the onset, he 
was always thoroughly conscious of his environ- 
ment and well oriented. His memory to his 
friends seemed unimpaired. He talked much 
about his many delusions, but always in a coherent 
manner. His delusions became altogether ex- 
pansive, referring exclusively to his transformation 
into a new being, his supernatural relations with 
God and the Virgin, his extraordinary powers, etc. 
He had no insight. He became wholly indifferent 
as to his own livelihood or the welfare of his sis- 
ters and careless of his personal appearance, while 



116 METHODS OF EXAMINATION 

his activities were confined to lounging about home 
and smoking a pipe. 

Status prsesens in the ninth month: — 

Perception. — Hallucinations of hearing are con- 
stantly present. These are mostly of a religious 
character and consist of conversations with God 
and the Virgin. "They talk to me about the 
things I am thinking of," etc. There are also con- 
stant hallucinations of touch, concerned mostly 
with sensations about the sexual organs. 

Consciousness is unclouded. 

Apprehension, unimpaired, and external impres- 
sions are correctly apprehended. 

Attention shows only a slight blunting and it 
requires some prodding to hold it. 

Memory. — The impressibility of memory shows 
some impairment, as patient fails to give correctly 
many events of his recent life and dates connected 
with his psychosis. On the other hand, retentive- 
ness of memory is excellent. He can detail cor- 
rectly all events of his early life. 

Orientation is correct as to time, place, and per- 
sons. 

Train of Thought. — The association of ideas is 
undisturbed except for some circumstantiality in- 
dulged in by the patient during the description of 
his delusional experiences, and some narrowness 



IN MENTAL DIAGNOSIS 117 

of thought shown by his limited voluntary speech, 
and his tendency to revert to the description of his 
delusions. 

Judgment. — There are very many expansive 
religious delusions, mostly fantastic in character, 
which also involve somatic delusions and a change 
of personality: "I am a new man, I am the hus- 
band of the Virgin Mary. I shall never die. John 
Wesley is in hell. I can bring him here this min- 
ute. I am a man of great strength because God 
works through me. My bowels, kidneys, and heart 
are all new. I was first pulled apart and then God 
put in new organs," and many other equally fan- 
tastic delusions. He fails to show insight into his 
condition, but, on the other hand, considers him- 
self of unusual intellect. His judgment on matters 
outside of his delusions is not particularly at fault. 

Capacity for mental work is reduced. In accord 
with his delusions, his close communion with the 
Deity renders it unnecessary for him to employ 
himself except in performing minor duties and 
for his own amusement, such as playing cards. 
"I will never work again because I belong to God." 

Emotionally, the patient is uniformly cheerful 
and happy and presents a feeling of well-being. 
"I feel fine, just elegant, never felt better. I am 
content to stay anywhere." All interest in earn- 



118 METHODS OF EXAMINATION 

ing a livelihood or in his relatives is lost in his 
exalted religious feelings. 

Volitionaltyy the only apparent disorder is a 
slight amount of anergy. He lounges about, 
doing little except for his own amusement, and 
is orderly. He converses readily when addressed^ 
and when requested does some light work. 

Physically , he is well nourished and the general 
physical and neurological examinations are nega- 
tive. Subsequent examinations during the suc- 
ceeding week added nothing new to the first men- 
tal status, except numerous additional fantastic 
delusions of the same sort as already described. 

Diagnosis. — Dementia prsecox, paranoid form 
of the first group, characterized by numerous hal- 
lucinations and fantastic delusions, progressive 
moderate paresis of thought and will, emotional 
deterioration, and impairment of memory. 

2. Dementia Paralytica (Paresis) 

Family History. — Good. 

Personal History. — Thirty years of age and a 
merchant by occupation. He had always been 
temperate in the use of intoxicants, but for several 
years had been an inveterate and excessive cigarette 
smoker and so much addicted to the habit that he 
was noticeably very nervous except when smoking. 



IN MENTAL DIAGNOSIS 119 

Syphilis is absolutely denied, but gonorrhoea ad- 
mitted. He was of a pleasing disposition and quite 
successful in business. 

Psychosis. — Onset rather sudden at thirty 
years of age. Immediately following death of 
child, he began to suffer from severe headaches 
and insomnia. These symptoms improved only 
slightly under treatment during the succeeding 
months, while the patient in addition complained 
of general malaise and gave evidence of increased 
emotional irritability. The more prominent men- 
tal symptoms did not appear until the end of the 
third month, when the patient was returned home 
in a dazed and greatly fatigued condition after 
an absence of eighteen hours. He remembered 
only that he had been in a "fast house." The 
following day for the first time he began to express 
expansive delusions ; he talked of various business 
schemes, purchased some unsatisfactory real estate, 
lent money to unreliable persons, and finally adver- 
tised in a daily paper to give away clothing. He 
boasted of feeling "fine and strong" when in 
reality he was below par physically. He would 
continue expansive, busy, and elated for several 
days, and would then become drowsy and inactive 
for a few days and would complain of illness, ex- 
pressing the fear that he would never recover. 



120 METHODS OF EXAMINATION 

He presented several such alternating periods. 
He did not, at any time, suffer from hallucinations 
or illusions, consciousness remained clear, and there 
was no apparent disorder of memory or thought. 
He was slightly overactive and busy with his 
schemes. 

He was first examined in the sixth week, follow- 
ing the appearance of the expansiveness. At this 
time, his mental status was as follows: — 

Perception, — Hallucinations and illusions not 
elicited. 

Consciousness is clear. 

Apprehension also clear and external impressions 
are correctly interpreted. 

Attention shows slight distractibility, as it is 
difficult to hold the patient's attention to subjects 
under discussion; he must and does talk constantly 
in spite of repeated urging to answer definite ques- 
tions, about his various expansive delusions, some 
of which are evidently suggested by the surround- 
ings and questions asked him. 

Memory. — Impressibility of memory is some- 
what impaired, as patient is not only unable to give 
an accurate account of his life during the recent 
month, but utterly fails to recognize photographs 
just previously shown him when mixed with a 
number of others. Retentiveness is very good. 



IN MENTAL DIAGNOSIS 121 

Orientation is perfect and he is able to give time 
correctly, to name the persons in his environment 
and the place. 

Train of Thought. — There is considerable volu- 
bility, the thought centring about the expansive 
delusions, but what is said is perfectly coherent. 

Judgment. — He expresses many expansive de- 
lusions, such as that he knows all about law and at 
the present time is trying a case involving millions ; 
he is a wealthy business man and is about to 
close one of the largest real estate deals that has 
ever been transacted in the city; at his large cloth- 
ing store, he gives away suits as an advertisement, 
etc.; he is strong and powerful and could beat 
the best Yale athletes (in reality weak and puny). 
He has no insight into his mental or physical con- 
dition and resents it when asked if insane. 

Capacity for mental work is impaired by his dis- 
tractibility and busyness, which prevent his apply- 
ing himself. 

Emotionally, the patient exhibits a marked feel- 
ing of well-being. "I am feeling perfectly fine, 
the best ever," etc. (See Fig. 29.) 

Volitionally, there is an evident pressure of activ- 
ity, as shown by his inabilitjr to sit quietly dur- 
ing the examination. He must be up and off 
attending to his affairs. He walks about the room 



122 METHODS OF EXAMINATION 

restlessly, handles various articles that he sees, 
and several times takes off and puts on again his 
coat. 

Conduct. — In addition to his general busyness, 
he is careless about his personal appearance and 
the manner of his eating. He sleeps little, retires 
late, and is up again in the early morning to look 
after his many affairs. 

Physically, he is poorly nourished and looks 
anaemic. Neurologically, he presents markedly 
increased tendon reflexes, a pronounced tremor of 
spread fingers, of tongue, lips, and facial muscles, 
unequal pupils, the right being contracted to 
small size and barely reacting to light, the left 
moderately dilated and also reacting sluggishly 
to light. Speech is slightly impaired, the patient 
being unable to pronounce " electricity " and " Mas- 
sachusetts artillery brigade" without some hesi- 
tancy and slurring. There is some incoordination 
of the facial muscles, shown when requested to 
successively close and open his eyes and mouth and 
to protrude his tongue. Patient can write well 
except for the irregularities caused by the tremor. 
There is no involvement of cutaneous sensibility 
or of station. 

When examined two weeks later: — 

Disturbance of perception has developed, as the 



IN MENTAL DIAGNOSIS 123 

patient is now complaining of occasional noc- 
turnal auditory hallucinations; he hears people 
shout out to him, "Go to hell," etc. In reaction to 
these, he exhibits some fear and agitation at night 
and calls for help. 

Consciousness is still clear and apprehension 
good. 

Attention is even more disturbed as the result of 
greater distractibility. 

Memory. — The impressibility of memory is 
still more impaired, and he cannot recall that he 
has seen the physician before and remembers noth- 
ing of the previous examination. However, re- 
mote knowledge and school knowledge are well 
retained. 

Orientation is slightly impaired for time and for 
persons, i.e. he fails on the month, day of month, 
and day of week, and persons about him are mis- 
taken for former acquaintances, one of them being 
denominated "the greatest speaker in the world." 

Train of Thought. — There is no other involve- 
ment of the train of thought than the circum- 
stantiality noted before. 

Judgment. — The same type of changeable ex- 
pansive delusions are voluntarily expressed in great 
profusion, while insight is still wanting. 

Emotionally, the same feeling of well-being exists, 



124 METHODS OF EXAMINATION 

though elation is more evident and at times accom- 
panied by boisterous laughter. On the other 
hand, there are periods at night when he suddenly 
becomes fearful and calls out for help. 

Volitionally, the pressure of activity has con- 
siderably increased, and the patient, now confined 
in his room, rushes about from place to place, 
constantly busy with trifles, makes and unmakes 
his bed, changes his clothing, writes innumerable 
letters, requests interviews with prominent indi- 
viduals, tries to sell merchandise, in fact is so busy 
that he seldom finds time to eat unless urged. 

Conduct. — In addition to what has already 
been stated, he is less able to care for himself and 
soils his clothing and bed. Otherwise he is amiable 
and pliable, causing trouble only by his careless- 
ness and restlessness. 

Physically, since last observation, patient had 
one epileptiform seizure, lasting one hour, during 
which the clonic movements of the limbs con- 
tinued from the onset. It was followed by a 
stuporous, befogged state, lasting several hours. 
The other physical signs remain unchanged. 

Diagnosis. — Dementia paralytica, expansive 
form, characterized by gradual development with 
cephalalgia and insomnia, in sixth week sudden 
appearance of expansiveness, slight distractibility, 



IN MENTAL DIAGNOSIS 125 

failing memory, feeling of well-being, and pressure 
of activity, at first alternating with periods of 
drowsiness and insight, but later becoming con- 
tinuous. 

Physically, by exaggerated tendon reflexes, 
faulty speech, general tremor, incoordination of 
facial muscles, epileptiform attack, and unequal 
Argyl-Robertson pupils. 

3. Melancholia 

Family History. — Good. 

Personal History. — A hard-working mother of 
four healthy children, whose early and married 
life had been quite normal except that she was 
always of a solitary disposition. 

Psychosis. — Onset gradual at fifty-four during 
convalescence from abdominal section for fibroi- 
dectomy, although previous to the operation she 
had complained for several months of headache 
and general malaise. The first symptom noted 
was increasing despondency with a vague feeling 
as if something harmful was going to happen. 
Within two weeks she became so much self-ab- 
sorbed that she could not attend to any household 
duties. Her fear increased, taking on a more 
definite form, so that she spoke of personal injury 
and especially feared poisoning. She then began 



126 METHODS OF EXAMINATION 

to express delusions of self-accusation, claiming 
that she had committed very many sins, had neg- 
lected her family, had stolen, and had betrayed 
her Christ. For fear her children would be pun- 
ished on her account, she attempted to asphyxiate 
them and herself. 

Within a month occasional auditory hallucina- 
tions of a depressive nature developed. She 
said that the devil talked to her and tried to 
tempt her, God's voice condemned her for wrong, 
and she could hear dear ones calling for help. 
Consciousness remained clear and apprehension 
undisturbed. Memory seemed undisturbed and 
orientation appeared good. Delusions of self- 
accusation, similar to those already expressed 
and more absurd, were continually expressed. 
There was no insight. Emotionally, fear was 
constantly present, both for the safety of her 
family and herself, fear of punishment, of mis- 
fortune, robbery, personal injury, and death. 
Despondency was also pronounced, and in re- 
action to these morbid feelings she was greatly 
agitated and moaned and cried considerably. 
Volitionally, there was evidently no pronounced 
disorder. In conduct, she was neat and tidy. 
She remained alone most of the time, bemoaning 
her wickedness and the fate of herself and family. 






IN MENTAL DIAGNOSIS 127 

In reaction to her fear, she would hide upon the 
approach of any one ; and for fear of poisoning, she 
ate sparingly of food. 

The patient was first examined in the third 
month, when her mental status was as follows: — 

Perception. — Hallucinations of sight and hear- 
ing are present, especially at night. In addition 
to the voices of God and the devil, she also hears 
angels chiding her. She can hear her children 
shout aloud for help while being persecuted for 
her sake. There are also foreboding noises under 
her bed and outside the window. There are illu- 
sions of hearing, as she misinterprets voices of 
those passing her room for those of enemies, the 
squeak of a door is the shriek of her child, etc. 
Hallucinations of sight are present mostly at night, 
when ghosts and the devil appear to her in fright- 
ful forms, and there are also visions of things burn- 
ing and of people being punished. 

Consciousness is clear. 

Apprehension is disordered, as shown by the 
illusions, but otherwise external impressions are 
correctly apprehended. 

Attention is absorbed in her depressive ideas, her 
hallucinations and illusions, so that it is impos- 
sible to hold the attention long enough to apply 
tests. 



128 METHODS OF EXAMINATION 

Memory. — Impressibility of memory is impaired, 
and many passing events are not recorded, although 
she is able to keep track of the most important 
daily events, such as her meals, visits, etc. Re- 
mote events are always recalled accurately. 

Orientation is well preserved for time, place, and 
persons. 

Train of Thought. — Her thought is focussed 
on her misery and she often repeats compulsively 
for hours at a time: "Oh, my God save me. 
Oh, my God save me," "Is there any hope for 
me?" etc. It is sometimes difficult to interrupt 
these mournful repetitions and obtain replies to 
questions. Answers, when obtained, however, are 
coherent and relevant. 

Judgment. — Many self-depreciatory delusions 
are constantly expressed, particularly of self-con- 
demnation, of injury to family, of persecution, of 
reference, and of a somatic nature. These delu- 
sions are firmly fixed and not systematized. The 
delusions of self-accusation are similar to those 
already cited. The ideas of injury to family are 
in great part associated with hallucinations; for 
instance, her daughters were killed last night, 
because she heard men below cutting them to 
pieces, etc. The persecution includes petty annoy- 
ances by those about her, who come to her purely 




Fig. 30. Melancholia, showing 
Apprehensiveness. 



IN MENTAL DIAGNOSIS 129 

for the purpose of increasing her misery, while the 
delusions of reference consist in the belief that the 
acts of all about her have some direct bearing upon 
her and are performed to cause her discomfort or 
misery. The somatic delusions are quite fantastic. 
She claims that her head has been transformed 
so that she has two heads, one of an animal and 
one of man, and that her body is so changed 
that she is part man, part woman, and part 
beast, and a most horrible object to gaze upon, 
etc. She has absolutely no insight into her con- 
dition. 

Capacity for mental work is completely destroyed 
by her intense fear and her reaction to her delu- 
sions and hallucinations. 

Emotionally , she presents persistent morbid fear, 
which is most intense at night. There is fear of 
torture, of personal injury, of frightful punish- 
ment, of starvation, of poisoning, and of death. 
She also fears for the safety of her family. 

Volitionally, there is no marked disorder. 

In conduct, she presents, in reaction to her fear, 
an intense degree of agitation. She moans and 
laments loudly by the hour, often tearing her hair 
and pulling out her eyebrows. She tremblingly 
crouches into a dark corner and covers her head 
when any one approaches. Her breathing is 



130 METHODS OF EXAMINATION 

shallow and rapid. She takes sparingly of food, 
is careless of her personal appearance, but not 
untidy. 

Physically, the weight has fallen and nutrition 
is much impaired, the skin is dry and somewhat 
sallow, the bowels are greatly constipated, and 
the appetite is very poor. The tendon reflexes 
are slightly reduced. 

Diagnosis. — Melancholia of involution, char- 
acterized by the gradual development of despond- 
ency with fear and delusions of self-accusation, 
later with hallucinations of hearing and sight, and 
delusions of persecution and of bodily transfor- 
mation and great agitation. 

4. Manic Depeessive Insanity 
(a) Manic Phase 

Family History. — Mother insane and confined 
in an insane institution many years. 

Personal History. — Normal infancy and child- 
hood. Had a grammar school education and was 
an apt pupil. She was even-tempered, industrious, 
and temperate. 

Psychosis. — At eighteen years, following an 
attack of influenza, she became despondent, dull, 
and sluggish. She would sit in one place all day 
without uttering a word. She took food only when 



IN MENTAL DIAGNOSIS 131 

urged, yet she knew where she was and would 
recognize friends. "It took a long time to get 
anything out of her," but no strange ideas were 
ever expressed. This period lasted five months, 
when she fully recovered and returned to work. 

After a lucid interval of six months, during 
which she was constantly employed, she suddenly 
became "greatly excited" and was sent to the 
hospital the same day. 

At the time of the first examination, the status 
praesens was as follows: — 

Perception. — Hallucinations of hearing are 
evidently present, because she shouts replies to 
friends whose voices she hears in an adjoining 
room. The content of the hallucinations is mostly 
conversational and does not influence her conduct 
to any extent. Illusions of hearing are also pres- 
ent, as she mistakes noises in the vicinity for the 
voices of acquaintances. 

Consciousness is somewhat befogged and external 
impressions are not correctly apprehended. She 
cannot describe her surroundings correctly and 
hence has a very faulty conception of her environ- 
ment. 

Attention. — Distractibility of attention is very 
evident. This is shown chiefly by her observing 
and commenting upon almost everything that she 



132 METHODS OF EXAMINATION 

sees or hears in her environment. One sentence 
is only half expressed before she sees or hears 
something else which directs her train of thought 
in another direction. In subtracting seven from 
one hundred successively, she never gets farther 
than seventy-nine before she is attracted to do or 
say something foreign to the question, and a penny 
dropped upon the floor regularly distracts her. 

Memory. — Because of the extreme distracti- 
bility and the disorder of the train of thought, it is 
very difficult to secure satisfactory evidence as to 
memory. From her fragmentary replies to ques- 
tions, it is evident that she recalls remote events 
quite accurately. On the other hand, impressi- 
bility is impaired, since she cannot give correct 
information as to events since the onset of her 
illness. Nevertheless, she sometimes surprises 
one by her recollection of some minute and unim- 
portant details. 

Orientation. — She is only slightly oriented as 
to time and is wholly disoriented as to place 
and persons. She knows the year, season, month, 
and approximately the day of the month, but she 
believes herself at home and addresses those about 
her as acquaintances and friends. 

Train of Thought. — She is exceedingly voluble 
and chatters away almost constantly, at times 



IN MENTAL DIAGNOSIS 133 

singing and at others shouting. The content of 
her speech shows clearly a flight of ideas, with 
occasional sound associations and rhymes; for 
instance, says voluntarily, "Oh, my father, yes, 
fatherland," which might be "Our Father who 
art in Heaven." "I don't like that place, I was 
there at eight o'clock in the morning. Don't 
say prayers in the morning. The coffee was good, 
but I did not eat breakfast, last, cast," etc. 

Judgment — It is difficult to judge accurately 
of her judgment because of her faulty re- 
sponses. Occasionally, she expresses fragmen- 
tary expansive delusions which are evidently soon 
forgotten, as they are rarely repeated ; for instance, 
" I am the Queen of the May ; see my beautiful 
gown [torn garments]. I have lots of money," etc. 
She has no insight as to her illness. 

Capacity for mental work is completely destroyed 
by her great distractibility, since one thing is 
hardly begun before another is undertaken, and 
this in turn is only half finished before she is dis- 
tracted to something else. 

Emotionally, she exhibits increased emotional 
irritability, rapid change of mood, and persistent 
morbid elation. Although she is generally happy 
and elated, laughs loudly, sings and runs about 
gleefully, she often shows sudden changes of mood 



134 METHODS OF EXAMINATION 

and upon slight provocation will become pas- 
sionately angry. At one moment she is pleasant 
and agreeable, while at the next she stamps her 
feet, curses, and jumps at one, trying to scratch 
one's eyes. 

Volitionally, there is marked pressure of activity. 
She is never still except when asleep. If forcibly 
held, her hands and feet are in constant motion, 
either in rhythm to a song or beating a tattoo. 
Her movements /are always purposeful and often 
graceful, but never constrained or stereotyped. 
She races about the room, leaps up on the window- 
sill, and then begins to sing a comic song, accom- 
panied by the wildest gestures, suddenly jumps 
to the floor and begins to dance a clog, and so on ; 
from one thing to another. Her conduct also in- 
dicates distractibility. 

Conduct. — Besides that already indicated she 
is filthy, smearing her person and room. She is so 
busy that she has to be urged to eat. She sleeps 
barely four hours daily and then only by catch 
naps. She tears her clothing into strips, makes 
festoons and decorates her person. 

Physically, nutrition is hardly impaired in spite 
of her great activity. The tendon reflexes are all 
exaggerated. 

Diagnosis. — Manic-depressive insanity; second 



IN MENTAL DIAGNOSIS 135 

attack — manic phase, characterized by press- 
ure of activity, flight of ideas, clouded conscious- 
ness, transitory expansive delusions, increased emo- 
tional irritability, and frequent changes of mood. 

(b) Depressive Phase* 

Family History. — There is no history of heredi- 
tary taint. 

Personal History. — Quite normal in all respects. 

Psychosis. — There is a history of an attack of 
" nervous prostration" lasting several months at 
twenty-eight, when patient was sad and could not 
work. This nervous prostration was not the out- 
come of overwork or of any known causative fac- 
tor. (This was undoubtedly her first attack.) 

Again at forty-four years, following the death 
of her father, patient showed profound and un- 
natural grief and for many months could not be 
reconciled, and was incapacitated for employ- 
ment. This probably constituted her second 
attack. 

Present attack — onset gradual at forty-six 
years of age, the only assigned cause being worry 
over her inability to pay off a mortgage. She be- 

*The first attack in previous case was of the depressive 
phase, but unobserved. 



136 METHODS OF EXAMINATION 

came profoundly despondent and feared punish- 
ment for having done wrong and thought her 
sisters were against her. Within a few weeks she 
attempted suicide and from this time was remorse- 
ful and feared being arrested and placed among 
criminals. She also became exceedingly sluggish 
and would stand and apparently ponder over her 
work for long periods of time. About the house 
she walked very slowly and it required a very long 
time for her to prepare the meals, while in speak- 
ing she talked not only very slowly, but in low 
tones. She never expressed hallucinations, con- 
sciousness was clear, and her orientation perfect. 
Likewise she seemed able to remember everything 
accurately. 

The status praesens at the time of the first ex- 
amination, which was in the third month, was as 
follows: — 

Perception. — Hallucinations are absolutely 
denied. 

Consciousness is clear and external impressions 
are correctly apprehended. 

Attention. — There is evident retardation of at- 
tention, as it requires considerable time for her to 
fix her attention upon tests. 

Memory. — Both the impressibility and the 
retentiveness of memory are unimpaired. If per- 



IN MENTAL DIAGNOSIS 137 

sisted with, she is able to give a coherent and 
relevant account of her life, including recent hap- 
penings, while all tests are correctly responded to. 

Train of Thought. — Retardation of thought is 
quite marked. Her responses to questions are 
slow and long drawn out, so that it requires a very- 
long time to elicit a history from her. On the 
other hand, her responses are coherent and rele- 
vant. Her voluntary speech is rather meagre and 
confined to such mournful expressions as : "I have 
been banished/' "I have put myself in hell," 
"I would be glad to die." These expressions are 
repeated over and over, interjected between her 
replies to questions. 

Judgment. — There are expressed voluntarily 
many delusions of self-accusation. ' 1 1 have sinned 
past forgiveness ; God will never forgive me," etc. 
She also expresses a feeling of inadequacy, some- 
times associated with disordered bodily sensa- 
tions: "I feel all used up, I am changed, I can't 
set my mind to things. My legs feel so different, 
as if they were not my own. Things don't taste 
the same. I feel so unnatural all over." Insight 
is wholly lacking: "I only wish I were insane." 
In matters other than her delusions, the patient 
shows good judgment. 

Capacity for mental work is greatly impaired by 



138 METHODS OF EXAMINATION 

the extensive retardation, which makes applica- 
tion difficult and almost painful. Furthermore, 
her despondency and delusional ideas are very 
distressing. 

Emotionally, the patient shows persistent mor- 
bid despondency. She is constantly bemoaning 
her wickedness, and never expresses a feeling of 
comfort or complacency. Often her countenance 
betrays fear, and she will admit that she fears her 
fate. 

Volitionally, there is marked retardation, seen 
in the slowness of her movements, both volun- 
tary and in obedience to command and her low 
and slow speech. At times, when most distressed, 
the retardation is less evident in the movements of 
the arms and trunk, as she will wring her hands 
and sway her body. 

Conduct. — She is tidy and able to care for her 
bodily needs, though she is somewhat careless of 
her personal appearance. She either sits or stands 
gazing about her, often with her hands clasped. 
She occasionally approaches those near her and 
bemoans her wickedness. In eating, going to 
and from meals, dressing and undressing, she is 
exceedingly slow. 

Physically, she is poorly nourished, her skin is 
somewhat dry and sallow. There is anorexia and 



IN MENTAL DIAGNOSIS 139 

moderate insomnia. The tendon reflexes are some- 
what sluggish. 

Diagnosis, — Manic-depressive insanity, de- 
pressive phase, third attack, characterized by 
psychomotor retardation, delusions of self-accu- 
sation, persistent emotional dejection, feelings of 
inadequacy and unnaturalness. 

5. Paranoia 

Family History. — Good. 

Personal History. — Educated in common school 
and at first engaged as a laborer, he ultimately be- 
came a skilled mechanic, holding a responsible 
position. He was a man of excellent habits, with 
an equable disposition, and enjoyed excellent 
health until the onset of his psychosis. 

Psychosis. — Onset gradual. At forty-three 
years of age he first began to complain to his wife 
that things were different at the shop; he could not 
please the superintendent, fellow- workmen behaved 
strangely, his tools and furnaces were tampered 
with, and he could not accomplish good work. 
He intimated to his employer that he had become 
jealous of fellow-workmen, and that he believed 
they were trying to undermine him. This ex- 
pressed, he finally resigned his position and after 
a rest of several months, upon the advice of his 



140 METHODS OF EXAMINATION 

physician, took work in another city. In his 
new environment he seemed less suspicious and 
troubled for a time; but this improvement was 
brief, since his former troubles reappeared with 
even greater force. Again his tools were tam- 
pered with and his metal spoiled for casting. The 
persecution became even more extensive and in- 
volved the Masonic Order, members of which had 
taken up the persecution. At the time of resign- 
ing from this factory he believed the church also 
had a hand in his persecution. He therefore 
withdrew from both the Masonic Order and the 
church. The minister was accused because he 
had sent his letter of membership to the church at 
his new home, and thus his wife was accused of 
being a party to his persecution. Hallucinations 
did not appear until this time, when he claimed 
that his wife had accomplices in the home, whom 
he could overhear plotting to get rid of him. In 
reaction to these hallucinations he became abu- 
sive and threatening toward his wife. The as- 
signed purpose of all of the persecution was to get 
rid of him. For this reason the wife was bringing 
colleagues to the house nightly, and the church and 
Masonic Order had banded together to aid her. 
When seen in public, he appeared pleasant and 
agreeable and unless the conversation was drawn 



IN MENTAL DIAGNOSIS 141 

into the matter of his persecutions, he would have 
been considered normal. Even after a duration 
of two years he conversed well, had a good mem- 
ory, and was as efficient as ever at his trade. 
Physically, the patient since and before the onset 
of the disease had suffered from nephrolithiasis 
and associated with it pronounced pyuria. A little 
later his aggressive attitude toward his wife neces- 
sitated his confinement. When examined at that 
time, the status prsesens showed : — 

Perception, — Occasional auditory hallucina- 
tions; he hears his wife and her accomplices in 
the building plotting further persecution, also pa- 
tients in the ward speak of men who have been 
intimate with his wife. He is unable to identify 
these men, but believes that they must be members 
of the crowd of persecutors ; but his chief annoy- 
ance comes from what he calls a " Burillic Ray," 
which can convey the human voice from fifty to 
seventy-five miles. Through this Ray he can hear 
voices of many persons. Hallucinations or illu- 
sions of other senses are not present. 

Consciousness is unclouded. 

Apprehension is undisturbed and patient is 
able to apprehend correctly external impressions. 

Attention is very good. 

Memory. — Both the impressibility and the re- 



142 METHODS OF EXAMINATION 

tentiveness of memory are unimpaired. The pa- 
tient is able to give a full and accurate account 
of his life up to the present time. 

Orientation is perfect in all respects. 

Train of Thought. — The association of ideas 
does not show any impairment, and the patient's 
responses are always coherent and relevant. 

Judgment. — The patient freely expresses many 
delusions of persecution and of personal injury, 
also delusions of an expansive nature, all of 
which are thoroughly systematized. He relates 
how his persecutors began their work over three 
years ago, at first being confined to attempts of 
his fellow-workmen to get him discharged, to 
which his superintendent later became a party, 
then upon change into another shop their re- 
newed persecution, aided by the Masonic Order. 
Later his church friends were involved, and finally 
his wife became a party to the persecution and 
had men come to the house for the purpose of 
making it more disagreeable for him. Then 
began a new form of persecution by means of 
mysterious electrical appliances which were 
played upon him and produced pain in different 
parts of the body, disturbed his sleep, and impaired 
his digestion. After two and a half years of this 
persecution, it was revealed to him by means of 




Fig. 31. Paranoia, showing the Erect 
Carriage and Important Attitude. 



IN MENTAL DIAGNOSIS 143 

the " Burillic Ray " that he really was an impor- 
tant personage selected as a legatee to a large 
fortune named in a certain " Rebecca Andrus 
Will." The purpose of the persecution, there- 
fore, was to get rid of him so that his persecutors 
might come into possession of the legacy. They 
therefore employed the Ray machine for sending 
currents through him, for disabling him with 
pain, and for reading his thoughts, causing him 
to suffer great agony. Wherever he went the 
persecution continued. He was deprived of his 
liberty and sent to the hospital to prevent his 
communicating with individuals who could aid 
him, and since coming to the institution the 
officers and physicians had established a Ray 
system of electric wires, controlled from the 
office, which continue the evil work. So severe 
was the torture at times that he despaired of his 
life. Furthermore, in accordance with a condi- 
tion named in the Andrus will, he had been com- 
pelled to marry a daughter of one of the physicians. 
There are four more years of persecution and then 
the affair would end and he would receive his 
liberty and the ninety thousand dollars. In con- 
nection with these delusions he also expressed 
retrospective falsifications of memory, i.e. it had 
now become clear to him in looking back over 



144 METHODS OF EXAMINATION 

his past life that certain actual occurrences which 
took place years before he was aware of the per- 
secution indicated even then that he had been 
chosen as a public martyr, but ultimately to 
receive a large legacy. 

There was no insight into his mental condition. 
His judgment on matters outside of his delusions 
was good. 

Capacity for mental work is interfered with. 
While patient reads much, writes letters, and cares 
for his quarters, he is often annoyed by the appli- 
cation of the " Rays " to such an extent that he 
has to give up and go to bed, complaining bitterly 
of pains in his abdomen. 

Emotionally y the patient shows no striking abnor- 
mality. At times he is depressed and angered over 
his persecution and physical suffering, while at 
others he is complacent and satisfied to be a pub- 
lic martyr to be honored with liberty and wealth. 

Volitionally, there is no disturbance. 

Conduct. — The patient is orderly, quiet, neat, 
and gentlemanly. He occupies much of his time 
in reading, writing, and conversing with fellow- 
patients — in fact, there is nothing in his conduct 
to indicate that he is disturbed. 

Physically, he is poorly nourished, suffers 
from nephrolithiasis and constant pyuria. 



IN MENTAL DIAGNOSIS 145 

Upon subsequent examinations the mental 
statuses were the same. The delusions were 
always coherently and definitely expressed, show- 
ing a perfect system of persecution with the 
definite purpose to dispose of him and secure the 
large legacy which he was to secure as a prize 
for his long suffering. They ultimately involved 
the environment to a greater extent and created 
ever more suspicion toward some of the officials. 
There were also short periods of a few days when 
he seemed to undergo more physical suffering 
and would exhibit greater apprehension for his 
own safety. 

Diagnosis. — Paranoia, characterized by sys- 
tematized delusions of persecution, of personal 
injury, and of an expansive nature, with retro- 
spective falsifications of memory, without evident 
deterioration of memory, thought, emotions, or 
volitions. 

6. Acute Alcoholic Hallucinosis 

Family History. — Good. 

Personal History. — Development normal. He 
was a steady, industrious cooper, who from an 
early age was addicted to the use of alcohol, at 
first very moderately, but from forty to excess. 
He drank mostly beer and whiskey, but was 



146 METHODS OF EXAMINATION 

never intoxicated, and always able to work 
regularly. 

Psychosis. — Onset rather sudden at fifty- 
three years of age. He had been tremulous and 
a little unsteady for some weeks and had been 
sleeping and eating poorly. Suddenly one night 
upon retiring he was aroused by hearing voices 
in the apartment below. His neighbor Smith 
said : " Jack has got to move." " Jack has been 
drinking/ ' etc. These hallucinations of hearing 
continued several nights and caused him great 
anxiety. Then at the shop he overheard men say 
to each other : " Jack has been drinking heavily. 
He will be discharged," etc. Even Smith's voice 
was heard recounting to fellow-workmen how 
heavily he drank at home. Although he con- 
tinued at work days, his nights became more 
and more restless. Almost all night he could 
hear men and women in the rooms below and 
outside his window talking about him. He heard 
them threaten to break in and carry him out of 
town and to tar and feather him. He was called 
vile names and accused of gross immorality with 
the neighbor's wife. After enduring one week 
of such persecution without complaining, he 
asked for leave of absence and went away on a 
visit, but aboard the train he could hear Smith 



IN MENTAL DIAGNOSIS 147 

and a gang telling people that he was a drunkard 
and a criminal, trying to escape from justice. 
While away he was bothered continuously day and 
night by these voices, and in addition at night 
" spirits appeared " and announced that they 
had come to kill him. He hastened home and 
went to the police for protection, claiming that 
Smith and a gang of men were down on him 
and threatening to kill him; that he could not 
find out the reason why, except that they believed 
him a drunkard and immoral. Throughout these 
two weeks he had remained perfectly conscious 
and oriented, thought was uninvolved, and mem- 
ory unimpaired. In reaction to his hallucina- 
tions and delusions, he had become fearful and 
despondent. 

It was at this time that the first mental status 
was made. 

Perception, — Almost constant hallucinations 
of hearing, and occasional hallucinations of 
sight and touch. The auditory hallucinations 
consist of the voices of neighbor Smith and his 
wife and a gang of men, who slander and threaten 
him, say they will see that he is put out of the 
way, etc. The hallucinations of touch are: " I 
feel something prick my ankles. I feel electricity 
in my arms when tying on my shoes. I have 



148 METHODS OF EXAMINATION 

felt and seen electricity go off the ends of my 
fingers." The hallucinations of sight consist of 
seeing small human figures dressed in fantastic 
costumes and again flashes of light, etc. 

Consciousness is clear and apprehension undis- 
turbed. 

Attention is not disordered. 

Memory is wholly unimpaired, and patient is 
able to give an accurate account of his early 
life and of his psychosis. 

Orientation is perfect and he is able to state 
accurately the time, place, and persons of his 
environment. 

Train of thought is not disordered at all. 

Judgment. — Patient expresses fixed unsystem- 
atized delusions of persecution which seem de- 
pendent upon his hallucinations; the neighbors 
Smith are persecuting him and want him killed. 
His shopmates have driven him from the shop 
and the city and are determined that he shall be 
imprisoned or killed. They have contrived some 
way of putting electricity on him and of making 
him dizzy-headed. The Smiths also administer 
laudanum, which makes him drowsy, and put 
stuff in his food. He knows of no reason for this 
persecution except that they regard him immoral 
and a drunkard. 



IN MENTAL DIAGNOSIS 149 

Capacity for mental work is disturbed by his 
hallucinations and delusions. 

Emotionally, patient shows persistent morbid 
fear and despondency, which is in accord with his 
hallucinations. 

Volitionally, there is no disorder. 

Conduct. — Patient is orderly, neat, and tidy. 
He works for short periods when requested to, but 
remains alone most of the time. He complains 
bitterly of his persecution and asks for protection 
and relief. 

Physically, he has lost in weight, eats sparingly, 
and sleep is much disturbed. There is a pro- 
nounced fine tremor of the hand, tongue, and lips. 
The tendon reflexes are considerably exaggerated. 

Diagnosis. — Acute alcoholic hallucinosis, char- 
acterized by the acute development of halluci- 
nations of sight, hearing, and touch, and asso- 
ciated with the hallucinations, delusions of perse- 
cution, and emotional despondency and fear, 
the consciousness remaining clear, and the mem- 
ory, attention, and train of thought unimpaired. 

7. Acute Confusional Insanity (Amentia) 

Family History. — Good. 
Personal History. — A small woman of nervous 
temperament who has always suffered from 



150 METHODS OF EXAMINATION 

dysmenorrhea. She was divorced at thirty-five 
after an unhappy and arduous married life, and 
then, in spite of ill health, had to support herself 
and child. 

Psychosis. — For six months preceding the 
mental breakdown, she had suffered greatly 
from endometritis and metrorrhagia and during 
the last three months had become markedly 
anaemic and was confined in bed. The onset of 
the psychosis was sudden during preparations 
for her removal to a general hospital for treat- 
ment. She became " delirious," had vivid hallu- 
cinations of sight and hearing, saw faces at the 
window, and the ghosts of her parents, heard her 
name called out, shouts of fire, ringing of bells, 
and crying of infants. Almost at once she became 
completely dazed and lost all conception of where 
she was; at one time she was " in a church being 
married " and at the next " at a grand party." 
Those about her were mistaken and closest friends 
greeted as strangers. Her attention wandered. 
She seemed to have no memory of passing events 
and would forget even that she had only just 
awakened and had taken her nourishment. She 
expressed many changeable delusional ideas, both 
expansive and depressive; claimed to be a god- 
dess, to be wealthy, to have a fine automobile, 



IN MENTAL DIAGNOSIS 151 

and almost in the same breath would say that 
she had been driven from home and deprived of 
her children, was in distress, and needed assistance. 
She was at times happy and at others depressed, 
and would chat cheerfully or would weep profusely. 
Again she would express fear, but all of these 
emotional states would be transitory and change 
rapidly. The excitement was intense and the 
pressure of activity marked, and it was with great 
difficulty that she could be kept in bed. She 
would attempt to leap out in order to rescue her 
child whom she heard crying, or to greet an old 
friend ; again in terror she would try to escape. 
She would sing loudly and again moan piteously. 
In conduct she was incapable of caring for herself 
and soiled her person. Food was refused or eaten 
hurriedly and there was practically no sleep. 

She was first seen on the third day, when the 
mental status was as follows: — 

Perception. — There are marked hallucinations 
of sight, hearing, touch, and taste. Though not 
always admitted, it is evident from her reaction 
that they are present. She sees faces about the 
room, sees and smells suffocating vapor pouring 
in at the door, sees and talks with her child and 
parents, and converses with God and the angels. 
She hears it remarked that an operation has been 



152 METHODS OF EXAMINATION 

performed on her and black hairs have been im- 
planted on her face so that she looks like a wild 
animal. She can feel these hairs on her face. 
She says she has given birth to a dog which she 
can feel beside her in bed. These and many 
more changing hallucinations are present day and 
night and are constantly reacted to. There are 
also illusions of sight and hearing. Objects on 
the wall are mistaken for moving things and 
persons, while conversations of others are mistaken 
for profanity, singing, etc. 

Consciousness is partially clouded and some 
external impressions are not correctly appre- 
hended, as may be judged from the illusions. 

Attention is extremely faulty because of the 
great distractibility. Her attention is attracted 
first to some moving object in her environment, 
then to a remark by some one, or to an halluci- 
nation or a depressive thought ; hence questions 
asked are rarely answered satisfactorily, and it 
is wholly impossible to secure any response to 
tests. 

Memory. — Both impressibility and retentive- 
ness are greatly disturbed and she cannot recall 
either recent or remote events accurately; for 
instance, she cannot give the age of her child, 
date of her marriage, and places of residence, 



IN MENTAL DIAGNOSIS 153 

and she has no idea of when she had her last 
meal, what she has eaten, or who has just visited 
her. 

Orientation is wholly lost and she has no con- 
ception of where she is, who those about her are, 
or the time of day, month, or year. 

Train of Thought. — She is extremely voluble, 
talking or singing most of the time. She presents 
a flight of ideas and frequent sound associations. 
She catches up a word from the conversation of 
the physicians, such as Middletown and begins 
to remark that it is a city in the centre of the state, 
but not the capital of Connecticut, but Governor 
Roberts is a good man who lives in Hartford. 
Then apparently in response to an hallucination, 
" Yes, mother, I shall be there ; put the potatoes 
on. Johnnie will soon be home. Johnnie comes 
marching home again. John Brown's body lies 
a-mouldering on the green grass growing all 
around," etc. 

Judgment. — She expresses voluntarily many 
changing delusions of an expansive and a somatic 
nature: that she is wealthy and will give jewels 
to all who come to her ball ; that there is war, and 
a massacre has taken place in which all of her 
people have been killed; also that she has had an 
operation, her ovaries have been removed and 



154 METHODS OF EXAMINATION 

replaced by dog's ovaries, impregnated with 
human semen, and that she has given birth to 
puppies; that she has died and is in heaven sur- 
rounded by hosts of angel friends, etc. Individual 
delusions are rarely held more than a couple of 
hours at a time, and are constantly giving place 
to new ones. 

Emotionally, she presents an increased emo- 
tional irritability with changeable mood. At 
times she is cheerful and happy and will sing and 
jest, and again she is sad and cheerless, weeping 
because all of her relatives and friends have been 
killed. At times she is even fearful, but de- 
spondency prevails. 

Volitionally, pressure of activity is pronounced. 
She sings and pounds the bed, pulls at the bed- 
ding, attempts to disrobe and to get out of 
her room. She will attempt to leap on the 
window ledge and exhort an imaginary crowd. 
She will pull the bedding apart, shove the bed 
about, and stuff the clothing out of the window. 
She cries aloud for help, attacks her nurses, and 
throws food away. The movements are not 
constrained or limited to a small range, but are 
all over the room. 

Conduct — In addition to what is already indi- 
cated, she is untidy and filthy, refuses to take 



IN MENTAL DIAGNOSIS 155 

nourishment, either casting it away or spitting it 
out of her mouth. 

Physically, marked secondary anaemia, endome- 
tritis, malnutrition, profound insomnia, and ex- 
aggerated tendon reflexes. 

Diagnosis. — Amentia, characterized by sudden 
onset with acute delirium, numerous hallucina- 
tions and illusions, clouding of consciousness, 
complete disorientation, distractibility of atten- 
tion, impaired memory, flight of ideas, change- 
able expansive and depressive delusions, change- 
able mood and pressure of activity. 



CHAPTER III 

Glossary of Terms commonly used in 
Psychiatry 

A 

Acceleration of Thought. — That disturbance of 
the train of thought in which the association of 
ideas is rendered more rapid. 

Acute Alcoholic Hallucinosis. — A form of acute 
alcoholic insanity characterized chiefly by the sud- 
den development of coherent delusions of persecu- 
tion, based mostly upon hallucinations of hearing 
with barely any clouding of consciousness. 

Agitation. — A state of mental excitement which 
arises from what appears to be a sufficient motive. 

Agoraphobia. — A form of compulsive insanity 
in which there is a morbid fear of being in public 
places, accompanied by certain nervous manifes- 
tations, such as polyuria. 

Alcoholic Hallucinatory Dementia. — A form of 
alcoholic insanity characterized chiefly by hallu- 
cinations, self-depreciatory and somatic delusions, 
some emotional anxiety and irritability, usually 

157 



158 METHODS OF EXAMINATION 

terminating after prolonged course in moderate 
dementia. 

Alcoholic Paresis. — Cases of dementia para- 
lytica in which symptoms of alcoholic insanity 
supervene. 

Alcoholic Pseudoparesis. — Cases of alcoholic 
hallucinatory dementia in which signs of Kors- 
sakow's psychosis also exist. 

Amentia. — One of the exhaustion psychoses 
of relatively short duration in which there is great 
confusion of thought, clouding of consciousness, 
hallucinations, and illusions. 

Anergy. — See paralysis of the will. 

Apprehension. — Act of mind in . which one 
grasps facts of the environment. 

Arrested paresis refers to a very small number 
of reported cases of paresis in which the disease 
process seems to have been indefinitely arrested. 

Arteriosclerotic Insanity. — That form of insan- 
ity which arises from arteriosclerosis of cerebral 
vessels and is characterized chiefly by faulty 
memory, lack of energy, some despondency, and 
irritability and certain physical symptoms, as syn- 
cope, dizziness, etc. 

Ascending Paresis. — That form of dementia 
paralytica which develops in connection with and 
subsequent to tabes. 



IN MENTAL DIAGNOSIS 159 

B 

Befogged State. — A state of clouded conscious- 
ness in which external and internal stimuli do 
not create clear presentations. 

Blocking of the Will. — A catatonic symptom in 
which acts are properly begun, but are soon in- 
terrupted or stopped by an opposing impulse ; for 
instance, the patient starts to open a door, but 
instead closes it, or begins to shake hands and then 
stops. 

Born Criminals. — One of the psychopathic per- 
sonalities in which there is an inadequate develop- 
ment of the moral feelings, resulting in conspicu- 
ous moral defects from youth up. 

Busyness. — A moderate degree of pressure of 
activity in which the patient is excessively busy 
in an orderly fashion. 



Catalepsy. — A form of transient hypersugges- 
tibility in which the limbs of a patient will remain 
in any position in which they are placed. 

Catatonia. — A form of dementia prsecox char- 
acterized particularly by certain states of stupor 
and of excitement. (See catatonic stupor and 
catatonic excitement.) 



160 METHODS OF EXAMINATION 

Catatonic Excitement. — A form of motor excite- 
ment characteristic of catatonia in which, in con- 
trast to manic excitement, the movements are 
purposeless, senseless, and often stereotyped. 

Catatonic Stupor. — That form of stupor in 
which every impulse is almost immediately fol- 
lowed by the release of an opposing impulse, which 
prevents the consummation of the act and pro- 
duces blocking of the will. 

Chronic Alcoholism. — A form of chronic alco- 
holic insanity characterized by varying degrees of 
mental and moral deterioration. 

Chronic Mania. — The name sometimes applied 
to those cases of manic-depressive insanity in 
which the manic attacks are very long. 

Circumstantiality. — A disturbance of the asso- 
ciation of ideas in which the train of thought is 
interrupted by the introduction of many non- 
essential and accessory ideas. 

Clouded Consciousness. — See befogged states. 

Collapse Delirium. — A form of exhaustion 
psychosis of short duration characterized chiefly 
by dreamy hallucinations, profound clouding of 
consciousness and confusion of thought, and great 
psychomotor activity. 

Compulsive Acts. — Acts usually accompanied 
by marked feelings, which seem to be forced upon 



IN MENTAL DIAGNOSIS 161 

one by the will of another, inasmuch as they 
do not arise from any conscious motive or 
desire. 

Compulsive Fear. — See phobia. 

Compulsive Ideas. — Ideas that irresistibly force 
themselves into consciousness. 

Compulsive Insanity. — A form of the insanity 
of degeneracy in which compulsive ideas and fears 
predominate and are usually accompanied by cer- 
tain physical sensations. 

Confusion. — A mental state characterized by 
incoherence of thought. 

Confusional Insanity (acute). — See amentia. 

Conscious Delirium. — A delirious state, occur- 
ring chiefly in epileptic insanity in which the pa- 
tients appear conscious of where they are and what 
they are doing. 

Constitutional Despondency. — A form of the 
insanity of degeneracy characterized by feelings of 
sadness which permeate all of life's experiences. 

Constitutional Excitement. — A form of the in- 
sanity of degeneracy in which there is a perma- 
nent but moderate psychomotor excitement. 

Constitutional Mania. — The name sometimes 
applied to constitutional excitement in which 
there occur periods of exacerbation similar to the 
manic phases of manic-depressive insanity. 



162 METHODS OF EXAMINATION 

Constraint. — Strained bodily attitudes exhib- 
ited particularly by catatonic patients. 

D 

Dazedness. — See befogged states. 

Dejection. — See depression. 

Deliria, Infection. — See infection deliria. 

Delirious Mania. — Those extreme manic states 
in manic-depressive insanity in which there is a 
pronounced dreamy clouding of consciousness, 
intense psychomotor activity, great incoherence 
of speech, marked flight of ideas, numerous hallu- 
cinations, and dreamlike delusions. 

Delirium. — A state characterized particularly 
by clouding of consciousness and often by various 
hallucinations and delusions, increased psycho- 
motor activity, and confusion of thought. 

Delirium, Acute. — (Provisionally described as 
a form of infection psychosis.) A delirious state 
of short duration and usually fatal outcome, which 
sometimes accompanies furunculosis, or follows a 
slight physical illness or may occur in the course 
of any other type of psychosis. 

Delirium, Anxious. — A delirium characterized 
by terrifying hallucinations and delusions, which 
occurs particularly in epileptics. 

Delirium, Collapse. — See collapse delirium. 



IN MENTAL DIAGNOSIS 163 

Delirium, Conscious. — See conscious delirium. 

Delirium, Fever. — See fever delirium. 

Delirium, Occupation. — A delirious state occur- 
ring most often in senile dementia in which the 
patient busies himself as if engaged in some definite 
occupation, as* cobbling. 

Delirium, Senile. — An acute form of senile de- 
mentia characterized by great clouding of con- 
sciousness, pronounced hallucinations, and deliri- 
ous conduct. 

Delirium Tremens. — A form of acute alcoholic 
insanity characterized chiefly by fantastic hallu- 
cinations of sight and hearing, some clouding of 
consciousness, agitation, and fear. 

Delusion. — A morbidly falsified belief which is 
not corrected by argument or experience. 

Delusions, Expansive. — All delusions of self- 
aggrandizement or exaltation. 

Delusions, Fantastic. — Delusions that are un- 
usually grotesque. 

Delusions, Hypochondriacal. — Delusions in 
which the patient believes himself afflicted with 
some grave disease. 

Delusions, Nihilistic. — Delusions in which the 
patient believes that objects are non-existent, 
sometimes even the patient himself. 

Delusions of Infidelity. — Delusions in which 



164 METHODS OF EXAMINATION 

the patient believes friends or relatives are un- 
faithful. 

Delusions of Influence. — Delusions in which the 
patient believes that he is under certain influences, 
mental or otherwise, exerted by others, such as 
hypnotic influences. 

Delusions of Mental Soundness. — Delusions in 
which the patient believes that he is mentally 
sound, constituting lack of insight into his dis- 
eased condition. 

Delusions of Persecution. — Delusions in which 
the patient believes he is persecuted. 

Delusions of Reference. — Delusions in which 
the patient believes that incidents in the envi- 
ronment necessarily refer to himself. 

Delusions of Self-accusation. — Delusions in 
which the patient believes he has committed some 
grievous fault. 

Delusions, Religious. — Those delusions that 
refer to the religious life of the patient. 

Delusions, Sexual. — Delusions involving the 
sexual life. 

Delusions, Systematized. — Delusions which are 
organized about some central idea or object. 

Dementia. — A mental state in which there is 
grave mental impairment, usually irrecoverable. 

Dementia Paralytica (paresis or general paralysis 



IN MENTAL DIAGNOSIS 165 

of the insane). — A fatal form of mental disease 
in which there develops profound dementia and 
various paralytic nervous symptoms. 

Dementia Paranoides. — A form of dementia 
prsecox, constituting the so-called first group of 
the paranoid forms in which there is rather rapid 
deterioration. 

Dementia Prcecox. — A common form of mental 
disorder occurring chiefly in the young, character- 
ized by a pronounced tendency to mental deterio- 
ration. (See hebephrenia, catatonia, and dementia 
paranoides.) 

Dementia Prcecox, Paranoid Forms. — Forms of 
dementia praecox characterized by persistent hallu- 
cinations and delusions. 

Depression. — A morbid emotional state char- 
acterized by sadness with a feeling of insufficiency. 

Desultoriness. — A disorder of the train of 
thought in which there is a complete loss of goal 
ideas. 

Deterioration. — See dementia. 

Dipsomania. — A mental state in which there 
develops periodically an insatiable craving for 
liquor. 

Disorientation. — A disorder of the intellect in 
which there is an inability to recognize one's 
relation to time, place, or persons. 



166 METHODS OF EXAMINATION 

Distractibility of Attention. — That disorder of 
attention in which it lacks unity and permanence 
and is dominated by all sorts of accidental external 
and internal influences. 

Dread Neurosis. — A form of psychogenic neu- 
rosis in which a feeling of anxious suspense more 
or less constantly dominates the life of the patient. 

E 

Echolalia. — A form of transient hypersugges- 
tibility in which the patient mimics what he hears. 

Echopraxia. — A form of transient hypersugges- 
tibility in which the patient mimics what he sees 
done. 

Emotional Attitude. — A subjective mental state 
characterized chiefly by specific feeling tones — 
the mental attitude toward self or environment. 

Emotional Deterioration. — An abnormal lack of 
feeling or emotional irritability. 

Entotic Hallucinations. — See auditory halluci- 
nations. 

Epileptic Befogged States. — States of clouded 
consciousness occurring in epileptic insanity. 

Epileptic Furor. — That form of epileptic insanity 
in which there are morbid impulses to violence. 

Epileptic Insanity. — Those forms of mental dis- 
order that accompany epilepsy. 



IN MENTAL DIAGNOSIS 167 

Epileptic Stupor. — A form of prolonged stupor 
that occurs in epileptic insanity independently 
of epileptic convulsions. 

Erythrophobia. — A form of compulsive insan- 
ity in which the patient has a morbid fear of 
blushing. 

Excitementj Catatonic. — See catatonic excite- 
ment. 

Exhaustion Psychoses. — Those forms of insan- 
ity that arise chiefly from exhausting factors, in- 
cluding collapse delirium, amentia, and chronic 
nervous exhaustion. 



Fabrication. — A disorder of memory in which 
pure invention is related as real experience. 

Fear (in pathology). — An abnormal state char- 
acterized by apprehensiveness. 

Feeling of Well-being. — That morbid emotion 
in which marked pleasurable feelings exist. 

Fever Delirium. — A form of infection psychosis 
arising in connection with and depending upon 
fever. 

Flexibilitas Cerea. — A form of catalepsy in 
which passive movements of a limb are met by a 
waxlike resistance which permits of the limbs being 
moulded into various positions. 



168 METHODS OF EXAMINATION 

Flights of Ideas. — A disorder of the train of 
thought in which the objects of thought change 
rapidly. 

Folie du Doute. — A form of compulsive insanity 
in which morbid fear takes the form of tormenting 
ideas. 

G 

Grumbling Mania. — A mild form of irascible 
mania. 

H 

Hallucinations. — Sense deceptions in which 
there are no recognizable external stimuli. (See 
hallucinations of hearing, etc.) 

Hallucinations , Dermal. — Hallucinations in- 
volving only the tactile sense. 

Hallucinations , Microscopic. — The false per- 
ceptions of minute objects crawling under the skin, 
particularly characteristic of cocaine psychoses. 

Hallucinations of Hearing. — Hallucinations 
that involve only the sense of hearing. 

Hallucinations of Sight. — Hallucinations that 
involve only the sense of sight. 

Hallucinations of Smell. — Hallucinations that 
involve only the sense of smell. 

Hallucinations of Taste. — Hallucinations that 
involve only the sense of taste. 



IN MENTAL DIAGNOSIS 169 

Hallucinations, Stable (Kahlbaum). — Those 
sense deceptions produced by the excitation of the 
so-called cortical sensory areas which are indepen- 
dent of the train of thought and of a fairly uni- 
form content, consisting of a repetition of senseless 
words, noises, etc. 

Hallucinosis. — A mental state in which hallu- 
cinations exist or predominate. 

Hebephrenia. — A form of dementia prsecox 
characterized by a gradual development of a sim- 
ple, more or less profound mental deterioration. 

Hyperprosexia. — A disorder of attention in 
which there is complete absorption of attention 
in some one object. 

Hypersuggestibility. — A disorder of volition in 
which patients tend to become the prey to every 
accidental influence. 

Hypnogogic Hallucinations. — Those sensory 
perceptions which occur in normal individuals, 
particularly at the onset of sleep, probably due to 
some excitation of the cortical sensory areas. 

Hypomania. — The mildest of the manic phases 
of manic-depressive insanity characterized chiefly 
by busyness. 

Hysterical Insanity. — Those forms of insanity 
that accompany hysteria. 

Hysterical Lethargy. — A form of hysterical in- 



170 METHODS OF EXAMINATION 

sanity, closely simulating normal sleep and usually 
accompanied by convulsions. 



Idiocy. — Arrested mental development of the 
most severe grade. 

Illusions. — Falsification of real percepts, e.g. 
the perception of a face where there is only a spot 
on the wall. 

Imbecility. — Arrested mental development of 
the light grade. 

Impulsions. — A form of compulsive insanity 
in which the compulsive fears take the form of 
impulses. 

Impulsive Acts. — Acts which are the outcome 
of a sudden overwhelming impulse arising within, 
which the patient does not have the opportunity 
to control. 

Inconsequential Speech. — See speech, inconse- 
quential. 

Infection Deliria. — Those forms of delirium 
that accompany typhoid fever, variola, malaria, 
acute chorea, influenza, hydrophobia, and certain 
septic states. 

Infection Psychoses. — Those forms of insanity 
that arise primarily from the toxins of infectious 



IN MENTAL DIAGNOSIS 171 

diseases, including fever delirium, infection deliria, 
and postfebrile psychoses. 

Insight. — The recognition on the part of the 
patient that he is mentally ill. 

Interference. — A disorder of volition occurring 
chiefly in catatonia in which the accomplishment 
of an intended act is interfered with by the inter- 
polation of incongruous impulses. 

Intoxication Psychoses. — Forms of insanity that 
develop as the result of the ingestion of toxic 
substances, including alcoholism, morphinism, 
cocainism, hasheesh, etc. 

Involution Psychoses. — That group of mental 
disorders that occur chiefly in the period of involu- 
tion, including melancholia, presenile delusional 
insanity, and senile dementia. 

Irascible Mania. — A mixed phase of manic- 
depressive insanity in which typical manic symp- 
toms are accompanied by a depressed emotional 
tone and not by elation. 

J 

Juvenile Paresis. — A form of dementia para- 
lytica that develops between the ages of ten and 
twenty and is characterized chiefly by simple 
deterioration accompanied by numerous paralytic 
attacks. 



172 METHODS OF EXAMINATION 

K 

Kleptomania. — That form of impulsive insan- 
ity in which there exists an irresistible impulse to 
steal. 

Korssakow's Psychosis. — That form of alco- 
holic insanity which is characterized chiefly by a 
profound disturbance of the impressibility of 
memory and of disorientation and by fabrications 
of memory. This name is also sometimes applied 
to the form of postinfection psychosis more com- 
monly called cerebropathia psychica toxsemica. 

L 

Lucid Intervals. — Periods of mental clearness 
occurring during the course of a mental disease. 

M 

Mania. — The term now properly applied only 
to the manic phases of manic-depressive insanity, 
which see. 

Mania, Chronic. — See chronic mania. 

Mania, Constitutional. — See constitutional 
mania. 

Mania, Grumbling. — See grumbling mania. 

Mania, Unproductive. — A mixed phase of 
manic-depressive insanity in which the typical 



IN MENTAL DIAGNOSIS 173 

manic symptoms are accompanied by a dearth 
of ideas and not by a flight of ideas. 

Manic-depressive Insanity. — A form of mental 
disorder characterized chiefly by the recurrence 
of manic or depressed states. 

Manic-depressive Stupor. — The stupor charac- 
teristic of the depressive phases of manic-de- 
pressive insanity produced by psychomotor re- 
tardation. 

Manic Excitement. — A form of motor excite- 
ment occurring in manic-depressive insanity in 
which, in contrast to catatonic excitement, the 
movements are purposeful. 

Manic Stupor. — A mixed phase of manic- 
depressive insanity in which the typical depressive 
symptoms are accompanied by emotional elation 
and not by the usual depression. 

Mannerisms. — A form of stereotyped move- 
ments in which ordinary movements are peculiarly 
modified; instance, carrying the arm in an 
unusual position. 

Masochism. — A form of perverted sexual in- 
stinct in which the endurance of pain increases 
or is substituted for sexual excitement. 

Megalomania. — The term commonly applied to 
the clinical picture presented by a patient suffering 
from the expansive form of dementia paralytica. 



174 METHODS OF EXAMINATION 

Melancholia. — A form of involution psychosis 
characterized chiefly by uniform despondency, 
with fear, delusions of self-accusation, of perse- 
cution, and those of a hypochondriacal nature. 

Memory, Impressibility of. — That aspect of 
memory in which impressions have residua. 

Memory, Retentiveness of. — Refers to the per- 
manence of residua. 

Menstrual Insanity. — The term sometimes ap- 
plied to periodical attacks of excitement occurring 
in female catatonics which seem to bear some 
relation to the menses. 

Monomania. — An obsolete name for paranoia, 
which see. 

Mood, Change of. — That emotional condition 
in which there is a temporary increase of emo- 
tional irritability, and a rapid change from one 
mood to an opposite mood. 

Moral Imbecility. — The name sometimes ap- 
plied to the severest forms of criminal endow- 
ment. (See born criminals.) 

Moral Insanity. — See moral imbecility. 

Morbid Emotions. — Feelings of unusual inten- 
sity and persistency which develop without suffi- 
cient cause. 

Morbid Liar. — That form of psychopathic 
personality characterized by a morbid hyper- 



IN MENTAL DIAGNOSIS 175 

activity of the imagination, inaccuracy of memory, 
and a certain instability of the emotions and 
volitions. 

Morbid Swindler. — See morbid liar. 

Morbid Temperament. — A disorder of the emo- 
tions in which there is a constitutional tendency 
to certain morbid feelings. 

Morphinism. — The form of insanity that arises 
from acute or chronic morphine intoxication. 

Motor Excitement. — See pressure of activity. 

Muscular Tension (in pathology). — A disorder 
of volition in which the patient remains in the 
same place or attitude for considerable periods 
of time, due to blocking of the will. 

Mutism. — A form of negativism in which the 
patient refuses to speak. 

Mysophobia. — A form of compulsive insanity 
in which there is a morbid fear of dirt or contagion. 

Myxedematous Insanity. — A form of insanity 
that sometimes accompanies myxcedema and is 
characterized by a progressive mental deteriora- 
tion. 

N 

Negativism. — A disorder of volition in which 
there is an impulsive resistance to all external 
influences. 



176 METHODS OF EXAMINATION 

Neologism. — The use of new or invented 
terms, some of which are altogether meaning- 
less, as " nutch," " strews," " dymantic." 

Nervousness. — A congenital morbid mental 
state in which there is a lack of symmetry in the 
development of the entire psychic personality 
and an inability to withstand the misfortunes of life. 

Neurasthenia (acquired). — One of the ex- 
haustion psychoses characterized chiefly by 
increased susceptibility to fatigue, increased 
emotional irritability, and numerous, mostly sub- 
jective, physical symptoms. 

Nocturnal Restlessness. — The restlessness 
shown chiefly by senile dements who wander at 
night. 



Occupation Delirium. — See delirium, occupa- 
tion. 

Onomatomania. — A form of compulsive insan- 
ity in which there is a compulsion to ponder 
over the names of persons. 

Organic Dementia. — A term applied in a 
limited sense to those psychoses that develop in 
connection with gross organic diseases of the cen- 
tral nervous system, including arteriosclerosis in- 
sanity, traumatic insanity, syphilitic insanity, etc. 



IN MENTAL DIAGNOSIS 177 



Paralysis of the Will. — A disorder of volition 
in which there is a more or less complete suspen- 
sion of volitional activity. 

Paralysis of Thought. — That disturbance of 
the train of thought in which there is a more or 
less complete absence of all association. 

Paranoia. — An irrecoverable form of mental 
disease ofj slow onset, characterized by pro- 
gressively systematized delusions, for many years 
unaccompanied by any dementia. 

Paresis. — See dementia paralytica. 

Perseveration. — A disorder of the train of 
thought, similar to simple persistent ideas, in 
which the patient repeats the name of objects 
previously indicated, when shown a different object. 

Polyneuritic Psychosis. — See cerebropathia 
psychica toxaemica. 

Postepileptic Insanity. — That form of epileptic 
insanity that develops immediately following a 
seizure, lasting from a few hours to several days. 

Postfebrile Psychoses. — See postinfection psy- 
choses. 

Postinfection Psychoses. — Those infection psy- 
choses that develop subsequent to the subsidence 
of fever. 



178 METHODS OF EXAMINATION 

Preepileptic Insanity. — A temporary form of 
epileptic insanity that develops immediately pre- 
ceding the epileptic convulsion. 

Presbyophrenia. — A form of senile dementia 
characterized chiefly by a marked disturbance of 
the impressibility of memory. 

Presenile Delusional Insanity. — One of the 
involution psychoses presenting many of the 
characteristics of dementia prsecox and in which 
there is a marked impairment of judgment with 
numerous unsystematized delusions of suspicion, 
and greatly increased emotional irritability. 

Pressure of Activity (motor excitement). — 
A condition in which there is greatly increased 
activity, which is out of proportion to the stimulus 
and the importance of the motive. 

Primary Traumatic Insanity. — An acute form 
of traumatic insanity which immediately follows 
the cerebral injury and is characterized chiefly by 
delirium. 

Pseudodipsomania. — The name applied to 
some of the unstable personalities that occa- 
sionally suffer from periods of excessive alcoholic 
intoxication. 

Pseudohallucinations. — Ideas of great sensory 
vividness. 

Pseudoquerulants. — One of the morbid per- 



IN MENTAL DIAGNOSIS 179 

sonalities resembling somewhat genuine queru- 
lants, but which never develop real delusions. 

Psychic Epilepsy. — That form of epileptic 
insanity in which various morbid mental states 
of excitement, stupor, etc., occur independently 
of epileptic convulsions. 

Psychic Hermaphroditism. — A contrary sexual 
instinct in which sexual feelings are exhibited 
toward both sexes. 

Psychogenic Neuroses. — Distinguished from 
other neuroses by the fact that some of the 
individual symptoms are of purely psychogenic 
origin. 

Psychomotor Retardation. — A disorder of voli- 
tion in which there is an impeded release of im- 
pulses so that all the actions are characteristically 
slow and weak. 

Psychopathic Personalities. — Mental deformi- 
ties in which there is a general deviation from 
normal life ; such as born criminals, morbid 
liars, etc. 

Psychosis (in pathology). — Any abnormal 
mental state or process. 

Pyromania. — A form of impulsive insanity 
in which there is an irresistible impulse to set 
fire. 



180 METHODS OF EXAMINATION 

R 

Rambling Thought. — The lightest form of 
flight of ideas in which the train of thought is 
constantly diverted by unimportant ideas, reminis- 
cences, and incidents, and has frequently to be 
led back to the original subject. 

Remissions. — An abatement of the mental 
symptoms. 

Resistance (in pathology). — The obstinate and 
persistent resistance shown by a patient under the 
influence of negativism. 

Retardation. — See psychomotor retardation. 

Retardation of Thought. — That disorder of the 
train of thought in which thought is slow and 
difficult. 



S 



Sadism. — A form of sexual perversion in which 
the person attempts to increase or induce sexual 
excitement by brutality. 

Senile Decay. — The term applied by Alzheimer 
to a combined form of senile dementia and arterio- 
sclerotic insanity. 

Senile Delirium. — See delirium, senile. 

Senile Delusional Insanity. — An uncommon 



IN MENTAL DIAGNOSIS 181 

form of senile dementia characterized chiefly by 
delusions, while orientation remains good. 

Senile Dementia. — One of the involution psy- 
choses characterized chiefly by a progressive mental 
deterioration. 

Sexual Delusions. — See delusions, sexual. 

Sexual Feelings, Perverted. — Any abnormality 
of the sexual instincts. 

Sexual Indifference. — A condition in which sex- 
ual feelings are more or less diminished. 

Sexual Neurasthenia. — The name sometimes 
applied to that form of nervousness in which the 
sexual impulse becomes the central point about 
which the entire life revolves. 

Simple Hypochondriacal Dementia. — A sub- 
group of hebephrenia in which hypochondriasis 
predominates. 

Simple Persistent Ideas. — A disorder of the 
train of thought in which some simple ideas per- 
sist in and dominate the train of thought. 

Simple Syphilitic Dementia. — A form of syphi- 
litic insanity which is characterized chiefly by a 
simple progressive mental deterioration. 

Simulation (in pathology). Feigning mental 
disease. 

Somatic Delusions. — Delusions that in any way 
refer to the patient's body. 



182 METHODS OF EXAMINATION 

Sound Associations. — Associations of ideas de- 
pendent upon similarity of sound, e.g. bell, hell, 
tell. 

Speech, Explosive. — The form of difficult enun- 
ciation shown chiefly by paretics in an effort to 
overcome their difficulties of articulation, in which 
each syllable or word is spoken abruptly and with 
marked emphasis. 

Speech , Hesitating. — A disorder of articulation 
shown chiefly by paretics and characterized by 
frequent pauses between syllables and words. 

Speech, Inconsequential. — A disorder of the 
train of thought, sometimes encountered in cata- 
tonia and hysterical insanity, in which the patient 
gives irrelevant answers to questions. 

Speech, Scanning. — A disorder of speech often 
occurring in paretics, in which there are frequent 
pauses between words and syllables and a rise and 
fall in the tone of voice. 

Speech, Slurring. — A disorder of speech, fre- 
quently occurring in paretics, in which there is a 
gliding over of poorly articulated sounds. 

Stupor. — The term usually applied to that dis- 
turbance of volition in which there is an impeded 
release of the volitional impulse, caused either by 
the presence of psychomotor retardation or block- 
ing of the will; instance, catatonic stupor. 



IN MENTAL DIAGNOSIS 183 

Stupor, Catatonic. — See catatonic stupor. 

Syphilitic Pseudoparesis. — That form of syphi- 
litic insanity in which the mental symptoms are 
accompanied by evidences of focal brain lesions. 

Systematized Delusions. — See delusions, sys- 
tematized. 



Tabetic Psychoses. — Those forms of insanity, 
exclusive of dementia paralytica, that may de- 
velop in connection with tabes, the most promi- 
nent of which is an acute hallucinosis. 

Taboparesis. — See ascending paresis. 

Tormenting Ideas. — One of the forms of com- 
pulsive insanity in which thoughts accompanied 
by feelings of apprehension constantly recur, such 
as onomatomania. 

Traumatic Dementia (posttraumatic constitu- 
tion). A chronic form of traumatic insanity char- 
acterized chiefly by various degrees of dementia. 

Traumatic Hysteria. — See traumatic neurosis. 

Traumatic Neurosis. — One of the psychogenic 
neuroses resulting from trauma, characterized 
chiefly by the gradual appearance of prolonged 
mental depression accompanied by numerous 
motor and sensory nervous symptoms. 

Typhoid Delirium. — The term sometimes ap- 



184 METHODS OF EXAMINATION 

plied to that infection psychosis which accom- 
panies typhoid fever. 

U 

Unstable, The. — The psychopathic personali- 
ties in which the patient presents a weakness of 
will in all of his activities. 



Verbigeration. — The term applied to the oral 
and written productions of catatonic patients 
which consist of an endless repetition of unintel- 
ligible words or scrawls. 






INDEX 



Acoustic nerve, 15. 

Action, disturbances of, 93. 

Acute Alcoholic Hallucinosis, 145, 

149. 
Acute Confusional Insanity, 149, 

155. 
Amentia (Acute Confusional In- 
sanity). 
Anergy, 95. 
Ankle clonus, 68. 
Apathy, 90. 
Aphasia, 52. 

Apprehension, disorders of, 63. 
Articulation, defects of, 23, 69. 
Attention, 63. 

Blocking of, 77. 

Blunting of, 76. 

Distractibility of, 77, 109, 
120, 131, 152. 

Passivity of, 77. 

Retardation of, 77, 136. 

Suppression of, 77. 



Befogged states, 76, 124, 131. 

Blood pressure, 70. 

Blood states in paresis, 70. 



Case-record, examples of, 54. 
Catalepsy, 94, 97, 112. 
Circumstantiality, 82, 84, 116. 
Confusion, desultory, 85. 
Consciousness, Clouding of, 76, 
152. 



Convulsion, 30. 
Cranial Nerves, 4. 

Olfactory, 4. 

Optic, 6. 
Cranium, measurements of, 66. 



Delusions, 85. 

Expansive, 86, 106, 110, 117, 
119, 121, 123, 133, 142, 
153. 

Fantastic, 117, 129. 

Nihilistic, 86. 

Of grandeur, 86. 

Of jealousy, 86. 

Of misfortune, 86. 

Of persecution, 86, 128, 142, 
148. 

Of self-aggrandizement, 86. 

Of self-depreciation, 86, 137. 

Sexual, 114. 

Somatic, 87, 88, 117, 128, 153. 

Systematized, 86, 88, 142. 

Unsystematized, 86, 128, 148 
Dementia Paralytica, 118, 124. 
Dementia Praecox, 101. 

Catatonic Form, 107, 113. 

Hebephrenic Form, 101, 107. 

Paranoid Form, 114, 118. 
Desultoriness, 82, 84, 105. 
Disorientation, 80. 

Amnesic, 81. 

Apathetic, 81. 

Delusional, 81. 

Person, 80, 132, 153. 

Place, 80, 132, 153. 

Time, 80, 153. 



185 



186 



INDEX 



E 

Echolalia, 94, 109, 110. 
Echopraxia, 94, 110. 
Ecstasy, feeling of, 90. 
Emotional deterioration, 90, 106. 
Emotional irritability increased, 

90, 92, 133, 154. 
Emotions, 64. 

Disturbances of, 90. 
Measurements, 91. 
Morbid, 90, 93, 110, 129, 138, 
149. 
Endothelial cells, 71. 
Epileptiform seizures, 124. 
Ergograph, 93, 99. 
Examination, 
Electrical, 42. 
Of Abducens, 7. 
Of eye-muscles, 

(a) Limitation of move- 
ment, 8. 
(6) Visual axes, 8. 

(c) Secondary deviation, 8. 

(d) Erroneous projection, 8. 

(e) Double vision, 9. 
(/) Position of head, 9. 

Of Motor Oculi, 7. 

Of muscle sense, 50. 

Of Patheticus, 7. 

Pain sense, 48. 

Physical, 4. 

Sense of touch, 44. 

Sensory, 11, 66, 69. 

Spine, 34. 

Temperature sense, 49. 

Trunk and Extremities, 24. 
Excitement, motor, 94. 

Catatonic, 110. 
Eye movements in dementia 
praecox, 67. 



Facial nerve, 14. 

Fatigue, increased susceptibility 

to, 89. 
Fear, morbid, 129. 



Feelings, 

Of hunger, 90. 

Of nausea, 90. 

Of pain, 91. 

Of shame, 91. 

Sexual, 91. 
Flexbilitas cerea, 94, 97, 112. 

G 

Gait, types of, 32. 
Glosso-pharyngeal nerve, 18. 

H 

Hallucinations, 63, 73, 104, 114, 
123, 127, 131, 141, 147, 
151. 

Heredity, 61. 

History, family, 3, 62. 

Personal, 3, 62. 
Hyperprosexia, 77. 
Hypoglossal nerve, 22. 



Ideas, compulsive, 82, 83. 

Flight of, 82, 84, 133, 153. 

Simple persistent, 82, 83. 
Illness, present, 4. 
Elusions, 63, 73, 75, 131, 151. 
Incoordination, 31, 122. 
Interference, 95, 96. 



Judgment, 64. 

Disturbances of, 85. 



Lumbar puncture, 71. 
Lymphocytes, 71. 

M 

Manic-depressive Insanity, 130. 

Depressive Phase, 135, 139. 

Manic Phase, 130, 134. 
Mannerisms, 95, 96. 



INDEX 



187 



Melancholia, 125, 130. 
Memory, 64. 

Disturbances of, 78. 

Fabrications of, 78, 79. 

Faulty impressibility of, 78, 
79, 104, 110, 120, 123, 
128, 152. 

Faulty retentiveness, 78, 105, 
152. 
Mental status, 72. 
Mental work, 

Capacity of, 89. 

Disturbances of, 89. 
Muscles, 66, 68. 

Power of, 26. 

Size of, 25. 
Mutism, 111, 112. 

N 

Negativism, 95, 98, 112. 
Neuritis, optic, 67. 
Nystagmus, 11. 



Orientation, 64, 105. 
Disturbances, 80. 



Paralysis, 27. 

Paranoia, 139, 145. 

Paresis (see Dementia Paralytica). 

Perplexity, 81. 

Perseveration, 82, 84. 

Plasma cells, 11. 

Pressure of activity, 110, 121, 

124, 134, 154. 
Psychomotor retardation, 94, 

138. 
Psycho-physical galvanometer, 

91, 93. 

R 

Reflexes, 

Achilles, 40, 68. 

Argyll Robertson, 37, 122. 



Reflexes, 

Babinski, 41, 68. 

Biceps-jerk, 38, 68. 

Cilio-spinal, 36, 67. 

Conjunctival, 8. 

Corneal, 36, 67. 

Cremasteric, 37. 

Deep, 35, 67. 

Exaggerated, 112, 149, 155. 

Front tap, 41, 68. 

Gluteal, 37. 

Hypogastric, 37. 

Jaw- jerk, 38, 68. 

Patellar or Knee-jerk, 38, 68. 

Pilcz-Westphal, 67. 

Plantar, 37. 

Psychic, 67. 

Pupillary, 37. 

Skin, 35, 36. 

Superficial, 35. 

Supinator, 38. 

Ulnar, 38, 68. 



S 

Skeleton, 25. 

Sound associations, 133, 153. 

Spasm, 29. 

Speech, disorders of, 69. 

Explosive, 69. 

Hesitating, 69, 122. 

Scanning, 69, 122. 

Slurring, 69. 
Spinal Accessory nerve, 21. 
Status Praesens, 64. 
Stereotypy, 95, 97. 
Stupor, catatonic, 111. 



Taste, special sense of, 12. 
Thought, Train of, 64. 

Disturbances of, 81. 

Paralysis of, 81, 83. 

Retardation of, 82, 83, 137. 
Tremor, 28, 122, 149. 
Trifacial nerve, 11. 



188 



INDEX 



U 
Unconsciousness, 76. 



Vagus nerve, 18. 
Vaso-motor and trophic disor- 
ders, 53. 
Visual fields, 67. 
Volition (see Will). 



W 

YY ell-beincr 

Feeling of, 90, 117, 119, 121, 
123. 
Will, 

Blocking of, 94, 96. 

Distractibility of, 94, 97. 

Hypersuggestibility of, 94, 112. 

Paralysis of, 94, 106. 
Writing scale, 93, 99. 



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